Biomechanical Consequences of Replacement of the Anterior Cruciate Ligament with a Patellar Ligament Allograft. Part I: Insertion of the Graft and Anterior-Posterior Testing*

Nineteen fresh-frozen knee specimens from cadavera were tested for anterior-posterior laxity with 200 newtons of force applied to the tibia. A cylindrical cap of subchondral bone containing the tibial insertion of the anterior cruciate ligament was isolated with a coring cutter and was potted in acrylic. A thin wire was connected to the undersurface of the cap, and relative displacement between the cap and the tibia was measured with an isometer as the knee was extended. The cap of bone was connected to a load-cell that recorded force in the intact ligament during anterior-posterior testing with the tibia locked in neutral, internal rotation, and external rotation. The anterior cruciate ligament was then resected, and a femoral tunnel was drilled at the site where the isometer readings from the wire were the same as those obtained for the intact anterior cruciate ligament. A bone-patellar ligament-bone graft was used to reconstruct the anterior cruciate ligament, and the isometer measurements were repeated with the graft in place. The graft was pre-tensioned at 30 degrees of flexion to restore normal anterior-posterior laxity. Anterior-posterior laxity tests were repeated at this level of pre-tension (laxity-matched pre-tension) as well as at a level that was forty-five newtons greater (over-tension). The moment required to extend the knee was measured before and after insertion of the graft at both levels of pre-tension. When the tibia was locked in positions of internal and external rotation, the anterior-posterior laxities and the forces in the anterior cruciate ligament (generated by an anterior force applied to the tibia) were significantly less than the corresponding values with the tibia in neutral rotation at 20, 30, and 45 degrees of flexion (p ≤ 0.05). Isometer readings for the intact anterior cruciate ligament indicated that the cap of bone retracted into the joint a mean and standard deviation of 3.1 ± 0.8 millimeters as the knee was extended from 30 degrees of flexion to full extension. For each specimen, the isometer measurements for the trial wire and for the graft were within 1.5 millimeters of those for the intact anterior cruciate ligament. At laxity-matched pre-tension (mean, 28.2 ± 16.8 newtons), the mean anterior-posterior laxities of the reconstructed knees were within 1.0 millimeter of the corresponding means for the intact knees between 0 and 45 degrees of flexion. Over-tensioning of the graft by forty-five newtons decreased the anterior-posterior laxity a mean of 1.2 millimeters at 30 degrees of flexion. Over-tensioning of the graft did not change the moment required to bring the knee to full extension. CLINICAL RELEVANCE: When performing an anterior laxity test with the knee flexed 20 to 30 degrees, the examiner should place the tibia in a position of neutral rotation, as this is the position of greatest laxity at which all anterior force applied to the tibia will be resisted by the anterior cruciate ligament. It is important to recognize that the intact anterior cruciate ligament does not behave in a so-called isometric fashion. Approximately three millimeters of retraction of a trial wire into the joint during the last 30 degrees of extension (as measured with an isometer) is reasonable in order to achieve changes in the length of the graft that approximate those of the intact anterior cruciate ligament.