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

Background For anterior cruciate ligament reconstruction with a double-bundle procedure, one of the major concerns is to not predispose either one of the grafts to risk of failure by overloading. Hypothesis Knee flexion angles between 15° and 45° for anteromedial graft fixation and 15° for posterolateral graft fixation are safe for both grafts in double-bundle anterior cruciate ligament reconstruction. Study Design Controlled laboratory study. Methods Nine human cadaveric knees were tested. The double-bundle anterior cruciate ligament reconstruction was conducted with both grafts fixed at 15° of knee flexion (fixation protocol 15/15) and again with the anteromedial and posterolateral grafts fixed at 45° and 15° of knee flexion (fixation protocol 45/15). For both fixation protocols, the knee kinematics and the in situ forces of the reconstructed anterior cruciate ligament and its individual grafts were measured and collected under an anterior tibial load of 134 N and combined rotatory loads of 10 N·m of valgus and 5 N·m of internal tibial torque. The data from both fixation protocols were compared with those of an intact knee. Results In response to the 2 external loading conditions, both fixation protocols (15/15 and 45/15) could restore the knee kinematics to within 2 mm of the intact knee (although statistically significant differences were found between fixation protocol 15/15 and the intact knee) and the overall in situ forces in the grafts similar to the intact anterior cruciate ligament. In response to the 134-N anterior tibial load, the in situ forces in the anteromedial graft for both fixation protocols did not exceed those of the intact anteromedial bundle. But at 30° and 45° of knee flexion, the in situ forces for fixation protocol 15/15 were 20.7% and 22.1% lower, respectively, when compared with the intact anteromedial bundle. Under combined rotatory loads, the anteromedial graft for fixation protocol 15/15 had in situ forces that were 45% lower than the intact anteromedial bundle at 30° of knee flexion. The in situ force in the posterolateral graft for both fixation protocols did not exceed those of the intact posterolateral bundle, nor were they significantly different from the intact posterolateral bundle at any of the flexion angles tested. Conclusion Both fixation protocols restored knee kinematics without predisposing either graft to failure. Therefore, knee flexion angles between 15° and 45° for graft fixation were found to be safe for t