The Effectiveness of Reconstruction of the Anterior Cruciate Ligament with Hamstrings and Patellar Tendon: A Cadaveric Study Comparing Anterior Tibial and Rotational Loads

Background: The objective of this study was to evaluate the effectiveness of reconstructions of the anterior cruciate ligament to resist anterior tibial and rotational loads. We hypothesized that current reconstruction techniques, which are designed mainly to provide resistance to anterior tibial loads, are less effective in limiting knee instability in response to combined rotational loads. Methods: Twelve fresh-frozen young human cadaveric knees (from individuals with a mean age [and standard deviation] of 37 ± 13 years at the time of death) were tested with use of a robotic/universal force-moment sensor testing system. The loading conditions included (1) a 134-N anterior tibial load with the knee at full extension and at 15°, 30°, and 90° of flexion, and (2) a combined rotational load of 10 N-m of valgus torque and 10 N-m of internal tibial torque with the knee at 15° and 30° of flexion. The kinematics of the knees with an intact and a deficient anterior cruciate ligament, as well as the in situ force in the intact anterior cruciate ligament, were determined in response to both loads. Each knee then underwent reconstruction of the anterior cruciate ligament with use of a quadruple semitendinosus-gracilis tendon graft and was tested. A second reconstruction was performed with a bone-patellar tendon-bone graft, and the same knee was tested again. The kinematics of the reconstructed knees and the in situ forces in both grafts were determined. Results: The results demonstrated that both reconstructions were successful in limiting anterior tibial translation under anterior tibial loads. Furthermore, the mean in situ forces in the grafts under a 134-N anterior tibial load were restored to within 78% to 100% of that in the intact knee. However, in response to a combined rotational load, reconstruction with either of the two grafts was not as effective in reducing anterior tibial translation. This insufficiency was further revealed by the lower in situ forces in the grafts, which ranged from 45% to 65% of that in the intact knee. Conclusions: In current reconstruction procedures, the graft is placed close to the central axis of the tibia and femur, which makes it inadequate for resisting rotational loads. Our findings suggest that improved reconstruction procedures that restore the anatomy of the anterior cruciate ligament may be needed.