Influence of Bundle Diameter and Attachment Point on Kinematic Behavior in Double Bundle Anterior Cruciate Ligament Reconstruction Using Computational Model
A protocol to choose the graft diameter attachment point of each bundle has not yet been determined since they are usually dependent on a surgeon’s preference. Therefore, the influence of bundle diameters and attachment points on the kinematics of the knee joint needs to be quantitatively analyzed. A three-dimensional knee model was reconstructed with computed tomography images of a 26-year-old man. Based on the model, models of double bundle anterior cruciate ligament (ACL) reconstruction were developed. The anterior tibial translations for the anterior drawer test and the internal tibial rotation for the pivot shift test were investigated according to variation of bundle diameters and attachment points. For the model in this study, the knee kinematics after the double bundle ACL reconstruction were dependent on the attachment point and not much influenced by the bundle diameter although larger sized anterior-medial bundles provided increased stability in the knee joint. Therefore, in the clinical setting, the bundle attachment point needs to be considered prior to the bundle diameter, and the current selection method of graft diameters for both bundles appears justified. 1. Introduction The anterior cruciate ligament (ACL) is one of the four major ligaments of the knee, which resists anterior translation and medial rotation of the tibia with respect to the femur. The ACL consists of two bundles, the anteromedial (AM) and posterolateral (PL) bundles. Biomechanical studies reported that the AM bundle generally experiences greater loads throughout the knee’s range of motion compared to the PL bundle, and the AM bundle is an important stabilizer of the knee in flexion, with lesser demands seen in extension [1, 2]. In contrast, the PL bundle restrains anterior tibial translation principally when the knee approaches extension and experiences very little strain in higher flexion angles [1, 2]. The AM bundle sees greater loads at all flexion angles whereas the PL bundle will see appreciable strain only at low flexion angles, so both the AM and PL bundles are important to the stability of the knee joint during the flexion-extension cycle [1–4]. In addition, anatomical studies revealed that the AM bundle usually was of greater diameter than the PL bundle although the data were variable according to specimen [5]. The ACL injury is usually treated surgically, and the double bundle ACL reconstruction has recently been conducted to achieve better outcomes than the single bundle reconstruction because the double bundle graft can replicate the function of the native
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