COPYRIGHT 2002

BY

THE JOURNAL

OF

BONE

AND JOINT

SURGERY, INCORPORATED

The Effectiveness of Reconstruction of the Anterior Cruciate Ligament with Hamstrings and Patellar Tendon
A CADAVERIC STUDY COMPARING ANTERIOR TIBIAL
AND

ROTATIONAL LOADS

BY SAVIO L-Y. WOO, PHD, AKIHIRO KANAMORI, MD, JENNIFER ZEMINSKI, MS, MASAYOSHI YAGI, MD, CHRISTOS PAPAGEORGIOU, MD, AND FREDDIE H. FU, MD
Investigation performed at the Department of Orthopaedic Surgery, Musculoskeletal Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania

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.

n recent years, reconstruction of the anterior cruciate ligament has been a standard treatment in the field of sports medicine for injury of the anterior cruciate ligament. After reconstruction of the anterior cruciate ligament, the instability of the knee in response to loads applied in the anterior direction is reduced1. Clinical data have suggested that this
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

procedure is successful2,3. However, the long-term results have shown that 11% to 30% of the patients had unsatisfactory results4,5, and some studies have questioned the effectiveness of reconstruction of the anterior cruciate ligament in preventing future degenerative changes in the knee6,7. The goals of reconstruction of the anterior cruciate ligament should be to restore the kinematics of the injured knee to those of the intact knee and to reestablish the in situ force in the graft to that in the intact anterior cruciate ligament. The current clinical assessments of reconstruction of the anterior


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 6 J U N E 2002 T H E E F F E C T I VE N E S S O F R E C O N S T R U C T I O N O F T H E A N T E R I O R C R U C I A T E L I G A M E N T W I T H H A M S T R I N G S A N D P A T E L L A R TE N D O N

cruciate ligament have been largely based on the ability of the surgical intervention to reduce anterior instability in response to anterior tibial loads3,5,8. Since the anterior cruciate ligament is known to be functional when the knee is subjected to valgus rotation as well as internal tibial torque9, the graft that replaces the anterior cruciate ligament should also be able to withstand these loading conditions. Thus, the research question is whether the current techniques for reconstruction of the anterior cruciate ligament are as effective in establishing resistance to internal tibial and valgus torque as they are in providing resistance to an anterior tibial load. The objective of the present study was to evaluate the function of two popular grafts for the replacement of the anterior cruciate ligament, i.e., the quadrupled semitendinosusgracilis tendon and the central third of the patellar tendon, in response to an anterior tibial load and combined rotational loads. The two grafts were selected because of their widespread clinical use. We hypothesized that current techniques for reconstruction of the anterior cruciate ligament, which are designed mainly to provide resistance to anterior tibial loads, are less effective in limiting knee instability in response to the combined rotational loads. To test this hypothesis, the kinematics of the knees in multiple degrees of freedom and the in situ forces in the intact anterior cruciate ligaments and in the grafts that replaced the anterior cruciate ligaments were measured with use of a robotic/universal force-moment sensor testing system1,2. Materials and Methods welve fresh-frozen human cadaveric knees from young individuals (mean age [and standard deviation], 37 13 years at the time of death) were used in the present study. The knees were stored in airtight plastic bags at 20C. Roentgenograms of the specimens were made and examined to ensure that there was no evidence of osseous abnormalities, deformities, or osteoarthritis. Prior to testing, each specimen was thawed overnight while in the bag at room temperature. Without removing the soft tissue surrounding the knee joint, the tibia and femur were cut approximately 20 cm from the joint line and were then secured within 6-mm-thick aluminum cylinders with use of an epoxy compound (Bond-Tite Products, Cleveland, Ohio). The femur was rigidly fixed relative to the base of the robotic manipulator (Puma 726; Unimate, Danbury, Connecticut), while the tibia was attached through the universal force-moment sensor (model 4015; JR3, Woodland, California) to the end-effector of the robotic manipulator (Fig. 1). The robotic manipulator can move the knee in six degrees of freedom, with a repeatability of 0.2 mm for translations and 0.2 for rotations. The universal force-moment sensor can measure three orthogonal forces and moments and has a working capacity of 900 N along its z axis (the axis perpendicular to the surface of the sensor), 450 N along its x and y axes (the axes along the surface of the sensor), and 50 N-m for moments along each of the axes. Repeatability of the universal force-moment sensor is within 0.2 N and 0.01 N-m for forces and moments, respectively. With the force feedback

from the universal force-moment sensor, the robotic/universal force-moment sensor testing system can also operate in a forcecontrol mode10-12. The coordinates of the joint were defined as previously described in the literature10,13-15. That is, the femoral axis passed through the insertions of the collateral ligaments perpendicular to the long axis of the femur and was defined as the axis about which flexion-extension occurred. The tibial axis ran lengthwise through the center of the tibia and was the axis about which internal-external rotation occurred. The third axis, the varus-valgus axis, was a floating axis and was defined as the cross product of the two fixed axes at each position of flexion. After a specimen was mounted into the robotic/universal force-moment sensor testing system, the path of passive flexion-extension of the intact knee was determined from full extension to 90 of flexion by moving the tibia through 1 increments of flexion while the forces and moments were minimized. This path served as the reference position to measure knee kinematics and provided the starting position at each angle of flexion for the loading portion of the test. Two external loading conditions were then applied to the knee: (1) a 134-N anterior load was applied to the tibia 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 was applied with the knee at 15 and 30 of flexion. The loading conditions were chosen to simulate clinical examinations, such as the Lachman test, the anterior drawer test, and the pivot-shift test.

Fig. 1

Schematic drawing of the robotic/universal force-moment sensor testing system (UFS). 6-DOF = six degrees of freedom.


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 6 J U N E 2002 T H E E F F E C T I VE N E S S O F R E C O N S T R U C T I O N O F T H E A N T E R I O R C R U C I A T E L I G A M E N T W I T H H A M S T R I N G S A N D P A T E L L A R TE N D O N

The resulting motions of the intact knee, including anteriorposterior translation, medial-lateral translation, proximaldistal translation, internal-external rotation, and varus-valgus rotation, were determined in response to both applied loading conditions. The anterior cruciate ligament was then transected arthroscopically, and the previously recorded motions produced in the intact knee were repeated by the robotic manipulator while the universal force-moment sensor measured the new forces and moments generated by the knee with the deficient ligament. The vector difference between the forces applied to the knee before the anterior cruciate ligament was transected and the induced forces measured after the ligament was transected is equivalent to the in situ force in the anterior cruciate ligament on the basis of the principle of superposition11,16. An additional test was performed such that the same external loads that were used for the intact knee were applied to the knee with the deficient anterior cruciate ligament, and the resulting motions of the knee were measured. Subsequently, reconstruction of the anterior cruciate ligament was done on the same knee with use of an endoscopic single-incision technique by a team of experienced orthopaedic surgeons17,18. Tibial and femoral tunnels were placed in a routine fashion with use of commercially available drillguides (PROTRAC [Smith and Nephew, Memphis, Tennessee] for the tibial tunnel, and a 7-mm-offset drill-guide [Arthrex, Naples, Florida] for the femoral tunnel). For tibial tunnel placement, the anterior horn of the lateral meniscus was used as an arthroscopic reference, as suggested by Jackson and Gasser19; thus, the tunnel was located in the posterior half of the tibial footprint of the anterior cruciate ligament. With use of the 7-mm-offset drill-guide, the posterior edge of the femoral tun-

nel was aimed so that it was placed 2 mm anterior to the posterior edge of the intercondylar notch at the eleven oclock or one oclock position20. This position of the femoral tunnel was designed to restore the anteromedial bundle of the anterior cruciate ligament. Reconstruction of the anterior cruciate ligament was first performed with use of a 7 to 8-mm quadruple semitendinosus-gracilis tendon (hamstrings) graft and then a 10-mm bone-patellar tendon-bone (patellar tendon) graft. The patellar tendon graft was fixed with a titanium interference screw in the femoral tunnel. Since there are many devices for fixation of the hamstrings graft, we conducted an informal survey of twelve experienced orthopaedic surgeons. Eight of the twelve surgeons primarily used a titanium button for femoral fixation, three surgeons used a biodegradable interference screw, and one surgeon used staple fixation. On the basis of the results from this survey, the Endobutton CL (Smith and Nephew) was chosen for femoral fixation of the hamstrings graft. Both types of graft were fixed in the tibia with use of a custom-made device to ensure the application of equal tension in both grafts (Fig. 2). Tension was applied to the grafts by fixing the tendons in a chamber that slides through a tube. A spring scale was used to pull on the chamber, and the tube was secured with two screws. Each graft was preconditioned by moving the knee between full extension and 90 of flexion while a 44-N pretension was applied to the graft for five cycles. During fixation, the knee was flexed to 30 and a 67-N posterior tibial load was applied. The graft was pulled with 44 N of tension and fixed. Both external loading conditions were applied to the knees after reconstruction of the anterior cruciate ligament, and the five-degrees-of-freedom motions of the reconstructed knees were recorded. The graft was then removed, and the previously recorded motions of the reconstructed

Fig. 2

Schematic drawing of the reconstruction of the anterior cruciate ligament with use of a bone-patellar tendon-bone graft with an interference screw for femoral fixation (A) and with a semitendinosusgracilis tendon graft with an Endobutton CL (Smith and Nephew) (B). The same custom-made device for tibial fixation was used in both graft complexes.


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 6 J U N E 2002 T H E E F F E C T I VE N E S S O F R E C O N S T R U C T I O N O F T H E A N T E R I O R C R U C I A T E L I G A M E N T W I T H H A M S T R I N G S A N D P A T E L L A R TE N D O N

TABLE I Anterior Tibial Translation (mm) in Response to an Anterior Tibial Load* Anterior Cruciate Ligament Position of Knee Full extension 15 of flexion 30 of flexion 90 of flexion Intact 4.9 1.9 6.1 2.8 6.6 3.3 5.4 2.6 Deficient 12.8 3.6 17.3 4.5 18.3 5.4 12.6 5.0 Reconstructed with Hamstrings Graft 8.0 2.4 10.7 2.7 10.7 3.4 6.4 3.4 Reconstructed with Patellar Tendon Graft 6.3 2.0 8.7 2.7 9.3 3.2 7.1 3.2

*The values are given as the mean and the standard deviation. P < 0.05 compared with the intact knees. P < 0.05 compared with the knees with a deficient ligament. P < 0.05 compared with the knees reconstructed with a hamstrings graft.

TABLE II Anterior Tibial Translation (mm) in Response to a Combined Rotational Load Involving Internal and Valgus Tibial Torque* Anterior Cruciate Ligament Position of Knee 15 of flexion 30 of flexion Intact 4.5 0.7 6.5 2.3 Deficient 10.8 3.0 11.3 3.1 Reconstructed with Hamstrings Graft 9.2 2.2 10.1 3.0 Reconstructed with Patellar Tendon Graft 8.2 2.0 9.4 2.9

*The values are given as the mean and the standard deviation. P < 0.05 compared with the intact knees. P < 0.05 compared with the knees with a deficient ligament. P < 0.05 compared with the knees reconstructed with a hamstrings graft.

knee were repeated in order to determine the in situ force in the grafts. Data on the five-degrees-of-freedom motions of the knees with an intact anterior cruciate ligament, with a deficient anterior cruciate ligament, and after the reconstructions, as well as the in situ force in the anterior cruciate ligament and in the two grafts in response to both loading conditions, were analyzed. Since all variables were measured within each specimen, statistical analysis of the anterior tibial translation and in situ force was performed with use of a two-factor repeatedmeasures analysis of variance. This analysis is sensitive to relative changes occurring within an individual knee, and thus specimen variability is minimized. Multiple contrasts were performed to evaluate the effects of reconstruction of the anterior cruciate ligament at specific angles of knee flexion. Significance was set at p < 0.05. Results n response to a 134-N anterior tibial load, the largest anterior tibial translation of the intact knees was a mean (and standard deviation) of 6.6 3.3 mm at 30 of knee flexion (Table I). Anterior tibial translation significantly increased at all flexion angles after transection of the anterior cruciate ligament (p < 0.05). The largest mean increase in anterior tibial translation after transection of the anterior cruciate ligament was 11.7 mm, which also occurred at 30 of knee flexion. After reconstruction of the anterior cruciate ligament with the hamstrings graft, the mean increase in anterior tibial translation was reduced to be-

tween 1.0 1.5 mm and 4.6 1.7 mm of that in the intact knees at 90 and 15 of flexion, respectively. After reconstruction with the patellar tendon graft, the mean increase in anterior tibial translation was reduced to between 1.4 1.7 mm and 2.7 1.3 mm of that in the intact knees at full extension and at 30 of flexion, respectively. When the data were normalized with respect to those for the knees with a deficient anterior cruciate ligament, the mean anterior tibial translation at 30 of flexion after reconstruction with the hamstrings and patellar tendon grafts was reduced to 60% and 52%, respectively, of that in the knees with a deficient ligament. In response to a combined rotational load, anterior tibial translation is a coupled knee motion. The coupled anterior tibial translation of the intact knees was a mean (and standard deviation) of 4.5 0.7 mm at 15 of flexion and 6.5 2.3 mm at 30 of flexion (Table II). In the knees with a deficient anterior cruciate ligament, the coupled anterior tibial translation was a mean of 10.8 3.0 mm at 15 of knee flexion and 11.3 3.1 mm at 30 of knee flexion, which represents a significant increase of 6.3 3.2 mm and 4.8 2.4 mm, respectively, compared with that in the intact knees (p < 0.05). After reconstruction of the anterior cruciate ligament with the hamstrings graft, the coupled anterior tibial translation changed little (9.2 2.2 mm at 15 of flexion and 10.1 3.0 mm at 30 of flexion) compared with that in the knees with a deficient ligament (p < 0.05). However, after reconstruction with the patellar tendon graft, the coupled anterior tibial translation was reduced somewhat more (8.2 2.0 mm


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 6 J U N E 2002 T H E E F F E C T I VE N E S S O F R E C O N S T R U C T I O N O F T H E A N T E R I O R C R U C I A T E L I G A M E N T W I T H H A M S T R I N G S A N D P A T E L L A R TE N D O N

TABLE III In Situ Force (N) in Response to an Anterior Tibial Load* Anterior Cruciate Ligament Position of Knee Full extension 15 of flexion 30 of flexion 90 of flexion Intact 112 26 129 16 129 19 98 26 Reconstructed with Hamstrings Graft 86 21 107 18 107 19 95 20 Reconstructed with Patellar Tendon Graft 101 25 114 24 115 20 82 22

*The values are given as the mean and the standard deviation. P < 0.05 compared with the intact knees. P < 0.05 compared with the knees reconstructed with a hamstrings graft.

TABLE IV In Situ Force (N) in Response to a Combined Rotational Load Involving Internal and Valgus Tibial Torque* Anterior Cruciate Ligament Position of Knee 15 of flexion 30 of flexion Intact 82 40 72 34 Reconstructed with Hamstrings Graft 37 23 36 22 Reconstructed with Patellar Tendon Graft 47 23 37 14

*The values are given as the mean and the standard deviation. P < 0.05 compared with the intact knees. P < 0.05 compared with the knees reconstructed with a hamstrings graft.

at 15 of flexion and 9.4 2.9 mm at 30 of flexion, p < 0.05) (Table II). Changes in the kinematics of the knee in other degrees of freedom were relatively small in response to both the anterior tibial load and the combined rotational loads. In response to the anterior tibial load, the mean differences between the intact knees and the knees with a deficient anterior cruciate ligament with respect to internal tibial rotation and valgus rotation were <3.5 and 1.6, respectively, whereas those for the medial-lateral translation and proximal-distal translation were <2.8 mm and 1.1 mm, respectively. In response to the combined rotational loads, the mean differences between the intact knees and those with a deficient anterior cruciate ligament with respect to internal tibial rotation and valgus rotation were <2.6 and 2.5, respectively, whereas those for medial-lateral translation and proximal-distal translation were <0.5 mm and 0.7 mm, respectively. The in situ forces in the intact anterior cruciate ligament under an anterior tibial load reached a mean peak (and standard deviation) of 129 16 N at 15 of knee flexion and remained at 129 19 N at 30 of knee flexion, but they were reduced to 98 26 N at 90 of knee flexion (Table III). Both of the grafts followed this same trend, i.e., the in situ forces in the hamstrings grafts and patellar tendon grafts reached a mean peak (and standard deviation) of 107 18 N and 114 24 N, respectively, at 15 of knee flexion and remained at 107 19 N and 115 20 N at 30 of knee flexion, but they were reduced to 95 20 N and 82 22 N at 90 of flexion. When comparing the in situ forces in the grafts, it is convenient to normalize the

data with respect to those for the intact anterior cruciate ligament (Fig. 3). The normalized in situ force in the hamstrings grafts and patellar tendon grafts was a mean (and standard deviation) of 78% 14% and 92% 19%, respectively, of that in

Fig. 3

The in situ force in the grafts, normalized to that in the intact anterior cruciate ligaments, in response to a 134-N anterior tibial load at a range of angles of knee flexion. The values are given as the mean and the standard deviation. An asterisk indicates a significant difference (p < 0.05).


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 6 J U N E 2002 T H E E F F E C T I VE N E S S O F R E C O N S T R U C T I O N O F T H E A N T E R I O R C R U C I A T E L I G A M E N T W I T H H A M S T R I N G S A N D P A T E L L A R TE N D O N

was a mean of only 45% and 61% of that in the intact ligament in response to combined rotational loads. The repeated-measures analysis of variance also indicated that there was an interaction between the condition of the knee (intact, with a deficient ligament, and reconstructed) and the angle of knee flexion for both of the dependent variables, i.e., anterior tibial translation and in situ force. This interaction indicates that the pattern of change in both the anterior tibial translation and the in situ force in the anterior cruciate ligament and the grafts were different throughout the range of flexion angles. These differences were due to the varying function of the anterior cruciate ligament and the graft as the angle of knee flexion changed. Discussion sing a robotic/universal force-moment sensor testing system, we evaluated the effectiveness of two popular grafts for reconstruction of the anterior cruciate ligament in response to an anterior tibial load and a rotational load. With motion of the knee allowed in all degrees of freedom and with use of the same starting positions at chosen angles of knee flexion, the knee motions in response to applied loads and moments as well as the in situ force in the hamstrings and patellar tendon grafts were compared for a range of knee flexion angles. In response to an anterior tibial load, the mean anterior tibial translation after both reconstructions of the anterior cruciate ligament was reduced to within 5 mm of that of the intact knees. Clinically, a reconstruction of the anterior cruciate ligament with a difference in anterior tibial translation of <5 mm

Fig. 4

The in situ force in the grafts, normalized to that in the intact anterior cruciate ligaments, in response to a combined 10-N-m valgus and 10-N-m internal tibial torque at 15 and 30 of knee flexion. The values are given as the mean and the standard deviation.

the intact anterior cruciate ligament, with the knees at full extension, and 101% 32% and 86% 25% of that in the intact ligament, with the knees at 90 of flexion; the differences between the in situ forces in the grafts were significant (p < 0.05 for both). With the number of specimens available, no significant differences could be detected between the in normalized situ force in the grafts with the knees at 15 and 30 of flexion. In response to the combined rotational load, the in situ force in the intact anterior cruciate ligament was a mean (and standard deviation) of 82 40 N with the knees at 15 of flexion and 72 34 N with the knees at 30 of flexion (Table IV). The mean in situ force in the hamstrings graft was only 37 23 N at 15 of knee flexion and 36 22 N at 30 of knee flexion. The mean in situ force in the patellar tendon graft was also decreased to 47 23 N at 15 of knee flexion and 37 14 N at 30 of knee flexion. With the number of specimens available, no significant differences could be detected between the normalized in situ forces in the grafts in response to the combined rotational load (Fig. 4). The normalized in situ force in the hamstrings grafts and patellar tendon grafts was a mean of only 45% 23% and 61% 25%, respectively, of that in the intact anterior cruciate ligament, with the knees at 15 of flexion, and 54% 25% and 65% 45% of that in the intact ligament, with the knees at 30 of flexion. The in situ force in the anterior cruciate ligament and in the grafts in response to combined rotational loads was significantly lower than that in response to anterior tibial loads. For example, with the knees at 15 of flexion, the normalized in situ force in the hamstrings and patellar tendon grafts was a mean of 83% and 88%, respectively, of that in the intact anterior cruciate ligament during anterior tibial loads, whereas it

Fig. 5

Anterior tibial translation in the reconstructed knees, normalized to that in the knees with a deficient ligament, in response to an anterior tibial load and a combined rotational load with the knee in 30 of flexion. The values are given as the mean and the standard deviation. An asterisk indicates a significant difference (p < 0.05).


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 6 J U N E 2002 T H E E F F E C T I VE N E S S O F R E C O N S T R U C T I O N O F T H E A N T E R I O R C R U C I A T E L I G A M E N T W I T H H A M S T R I N G S A N D P A T E L L A R TE N D O N

Fig. 6

Normalized in situ force in the grafts in response to an anterior tibial load and a combined rotational load with the knee in 15 of flexion. The values are given as the mean and the standard deviation. An asterisk indicates a significant difference (p < 0.05).

compared with that in the intact knee is considered normal or nearly normal21,22. In that sense, the reconstructions of the anterior cruciate ligament in the present study can be considered to have restored stability under an anterior tibial load. It is of interest that the patellar tendon graft reduced the anterior tibial translation more than the hamstrings graft did at lower angles of knee flexion, but no difference between the grafts was detected with the knees at 90 of flexion. Also, the mean in situ force in the patellar tendon graft was closer to that in the intact anterior cruciate ligament with the knees at full extension. However, with the knees at 90 of flexion, the mean in situ force in the hamstrings grafts (95 N) was significantly higher than that in the patellar tendon grafts (82 N) (p < 0.05). In response to the combined rotational load, anterior tibial translation is a coupled knee motion because the resulting motion occurs in a different direction than that of the applied load. Reconstruction of the anterior cruciate ligament with use of the two popular grafts was not as effective in reducing the coupled anterior tibial translation in response to a combined valgus and internal tibial torque as it was in reducing anterior tibial translation in response to an anterior tibial load, thus proving the hypothesis. A previous study from our research center revealed that a deficiency in the anterior cruciate ligament leads to an increase in coupled anterior tibial translation under the combined rotational load9; however, after reconstruction of the anterior cruciate ligament with use of the hamstrings and patellar tendon grafts, the coupled anterior tibial translation still remained at >87% and 78%, respectively, of that for the knees with the deficient anterior cruciate ligament (Fig. 5). Also, the mean in situ force in the

hamstrings and patellar tendon grafts was <45% and 61%, respectively, of the force in the intact anterior cruciate ligament (Fig. 6). The anterior cruciate ligament is known to have two major components, namely, the anteromedial and posterolateral bundles23, which function differently during passive knee motion. In response to an anterior tibial load, the posterolateral bundle plays a major role when the knee is near full extension, whereas the forces in the anteromedial bundle are relatively constant throughout flexion-extension24. It has also been shown that both bundles play a role in resisting the combined rotational load25,26. However, procedures for reconstruction of the anterior cruciate ligament have been focused on reproducing only the anteromedial bundle of the anterior cruciate ligament since this bundle has been observed to resist anterior tibial loads24,27. When it is placed at the femoral insertion of the anteromedial bundle, the graft is close to the central axis of the femur and tibia, which makes it insufficient to resist externally applied rotational loads. Recently, awareness of this potential reason for failure of such grafts has increased28. The present study had some limitations. First, the order in which the reconstructions of the anterior cruciate ligament were performed was not randomized. This limitation could not be overcome because the interference screw used for fixation of the patellar tendon graft destroyed the bone tunnel for the hamstrings graft; therefore, the reconstruction with the hamstrings graft was done first. Although this order may have had some effect on the results, testing of the two reconstructions in the same knee was essential for increasing statistical power and, therefore, a smaller number of specimens was required because the interspecimen variability was reduced. It is also well recognized that an interference screw is a standard fixation device for patellar tendon grafts, whereas many devices are advocated for the fixation of hamstrings grafts. The results of the present study suggest that a more anatomic reconstruction of the anterior cruciate ligament, which restores the morphology of the intact anterior cruciate ligament, might be necessary to improve the response to rotational loads29. Potential solutions, which include a more lateral placement of the graft in the femur or a double-bundle reconstruction of the anterior cruciate ligament, could be evaluated with use of the technology described here. Furthermore, more realistic loading conditions, including those used in clinical examinations and during the activities of daily living, should be investigated so that proposed improvements can be evaluated scientifically.
NOTE: The authors would like to acknowledge the technical assistance of Dr. Richard E. Debski and Dr. James A. Fenwick.

Savio L-Y. Woo, PhD Akihiro Kanamori, MD Jennifer Zeminski, MS Masayoshi Yagi, MD Christos Papageorgiou, MD Freddie H. Fu, MD


THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG VO L U M E 84-A N U M B E R 6 J U N E 2002 T H E E F F E C T I VE N E S S O F R E C O N S T R U C T I O N O F T H E A N T E R I O R C R U C I A T E L I G A M E N T W I T H H A M S T R I N G S A N D P A T E L L A R TE N D O N

Department of Orthopaedic Surgery, Musculoskeletal Research Center, University of Pittsburgh, E1641 Biomedical Science Tower, 210 Lothrop Street, P.O. Box 71199, Pittsburgh, PA 15213. E-mail address for S.L-Y. Woo: ddecenzo@pitt.edu In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the

National Institutes of Health (Grant AR 39683). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References
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