Biomechanical effects of medial-lateral tibial tunnel placement in posterior cruciate ligament reconstruction

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1 ELSEVIER Journl of Orthopedic Reserch 21 (23) Journl of Orthopedic Reserch Biomechnicl effects of medil-lterl tibil tunnel plcement in posterior crucite ligment reconstruction Keith L. Mrkolf *, Dvid R. McAllister, Chrles R. Young, Justin McWillims, Dniel A. Okes Biomechnics Resenrch Section, UCLA Deprtment of' Orthopedic Surgery, University of Cliforni t Los Angebs. Room UCLA Rehbilittion Center, 1 Vetern Avenue, Los Angeles, CA 995, USA Abstrct With most posterior crucite (PCL) reconstruction techniques, the distl end of the grft is fixed within tibil bone tunnel. Although surgicl gol is to locte this tunnel t the center of the PCL's tibil footprint, errors in medil-lterl tunnel plcement of the tibil drill guide re possible becuse the position of the tip of the guide reltive to the PCL's tibil footprint cn be difficult to visulize from the stndrd rthroscopy portls. This study ws designed to mesure chnges in knee lxity nd grft forces resulting from ml-position of the tibil tunnel medil nd lterl to the center of the PCL's tibil insertion. Bone-ptellr tendon-bone llogrfts were inserted into three seprte tibil tunnels drilled into ech of 1 fresh-frozen knee specimens. Drilling the tibil tunnel 5 mm medil or lterl to the center of the PCL's tibil footprint hd no significnt effect on knee lxities; the grft pretension necessry to restore norml lxity t 9" of knee flexion (lxity mtch pretension) with the medil tunnel ws 13.8 N (29%) greter thn with the centrl tunnel. During pssive knee flexion-extension, grft forces with the medil tibil tunnel were significntly higher thn those with the centrl tunnel for flexion ngles greter thn 65" while grft forces with the centrl tibil tunnel were not significntly different thn those with the lterl tibil tunnel. Grft forces with medil nd lterl tunnels were not significntly different from those with centrl tunnel for 1 N pplied posterior tibil force, 5 Nm pplied vrus nd vlgus moment, nd 5 Nm pplied internl nd externl tibil torque. With the exception of slightly higher grft forces recorded with the medil tunnel beyond 65" of pssive knee flexion, errors in medil-lterl plcement of the tibil tunnel would not pper to hve importnt effects on the biomechnicl chrcteristics of the reconstructed knee. 22 Orthopedic Reserch Society. Published by Elsevier Science Ltd. All rights reserved. Introduction Reconstruction of the posterior crucite ligment (PCL) is performed less frequently thn the nterior crucite ligment (ACL). Indictions for the procedure re less well defined nd often controversil [9]. Clinicl results of PCL reconstruction hve generlly been less stisfctory thn those for the ACL nd residul posterior lxity is not n infrequent occurrence [ 1,9,11,17]. The bsic science of PCL reconstruction hs not received the ttention devoted to ACL reconstruction. This is especilly true of lbortory studies relted to technicl spects of the procedure which could potentilly ffect the biomechnicl chrcteristics of the reconstructed knee. *Corresponding uthor. Tel.: ; fx: E-mil ddress: kmrkolf@mednet.ucl.edu (K.L. Mrkolf). The most common method of PCL reconstruction utilizes grft which psses into nd is fixed within trns-tibi1 tunnel. This tunnel is typiclly drilled using guide which is plced into the knee through n nterior incision. The surgicl gol is to locte the tip (or trget point) of the guide within the PCL's tibil insertion. Theoreticlly centrl loction within the PCL's tibil footprint would plce grft fibers t fvorble position to reproduce knee kinemtics during flexion-extension cycle, nd help estblish norml nterior-posterior (AP) knee lxity ptterns. Most uthors dvocte using intr-opertive X-rys or fluoroscopy to ssist with plcement of the tibil tunnel [9]. This is usully done in the lterl plne to confirm dequte superior-inferior position of the tibil tunnel, nd to prevent excessive penetrtion of the drill through the posterior cortex. Rcnelli nd Drez [18] hve described plcing the tip of the drill guide pproximtely 1 cm below the joint line. Although most commercilly vilble drill guides re mde to position /3/$ - see front mtter 22 Orthopedic Reserch Society. Published by Elsevier Science Ltd. All rights reserved. PII: S ( 2) 1 4-3

2 178 K L Murkdf et 1 I Journul of Orthopedic Rereurcli 21 (23) the guide pin fixed distnce below the tibil plteu, there is no control of medil-lterl plcement of the guide tip. Although the tibil insertion of the PCL is extrsynovil [19], it cn sometimes be viewed directly with the rthroscope. However$ is possible tht surgeons using drill guide could locte the tibil tunnel medil or lterl to the center of the PCL's tibil tt chment. Multiple studies hve documented the importnce of femorl tunnel plcement nd hve shown tht nonisometric positioning of the grft best corrects bnorml posterior lxity [24,6]. Bomberg et l. [3] nd Gllowy et l. [6] concluded tht the femorl tunnel should be plced in the nterior nd distl portion of the ntive PCL footprint to optimlly restore posterior knee lxity. Gllowy et l. [6] hve shown smll differences in AP knee lxity with medil nd lterl plcement of the tibil tunnel. However, the effects of such errors in tunnel plcement upon the pretension necessry to restore norml AP lxity nd upon ctul grft forces re unknown. The objectives of this study were to mesure lxity mtch pretension (the grft pretension necessry to restore norml AP lxity t 9" of flexion), AP knee lxities t five knee flexion ngles, nd grft forces generted during knee loding tests with tibil tunnel locted t the center of the PCL's tibil footprint, nd with tunnels 5 mm medil nd lterl to the centrl loction. Mterils nd methods Ten fresh-frozen cdveric knee specimens ged yers were used; the verge ge ws 56 yers. Ech knee ws tested mnully for stbility nd inspected visully for intr-rticulr pthology through medil prptellr incision. The femur nd tibi were potted in cylindricl molds of polymethylmethcrylte for gripping in the test fixtures. Soft tissues round the knee were left intct during testing. A cylindricl block of bone contining the PCL's femorl origin ws mechniclly isolted nd ttched to custom designed lod cell mounted on the femur [13,14]. The knee ws plced in lxity test pprtus, n AP force (i2 N) ws mnully pplied to n undercrrige br ttched to the tibil fixture of the pprtus, nd tibil displcement ws recorded using spring-loded trnsducer [12]. The tibi ws fixed in neutrl rottion during the tests; neutrl rottion t ech flexion ngle tested ws defined s midwy between the tibil rottions produced by 5. Nm of internl nd externl tibil torque. Lxity testing ws performed t O", 3", 6", 9", nd 12" of flexion. Zero degrees flexion ws defined s the ngle between the tibil nd femorl PMMA potting cylinders which resulted from ppliction of 2.5 Nm extension moment to the tibi. Knee lxity ws defined s the totl AP displcement of the tibi reltive to the femur between the limits of 2 N nterior tibil force nd 2 N posterior tibil force. A posterior rthrotomy ws mde, the PCL ws excised, nd n 11 mm tibil tunnel hole ws drilled t the center of the PCL's tibil footprint. The tip of the guide ws positioned under direct visuliztion through smll posterior incision. The ngle mde between the drill nd tibil plteu ws pproximtely 6". Grfts were prepred from tibi-ptellr tendon-ptell specimens obtined from tissue bnk; the men ge of the donors ws 43 yers. Ech specimen ws split longitudinlly into two hlves, yielding two grfts per specimen. A 1 mm wide grft ws prepred using the centrl portion of ech hlf. The bone blocks of the grfts were reduced to size tht would llow pssge through n I1 mm dimeter tunnel. Both bone blocks of the grft were interwoven with dul strnds of highly flexible 1.1 mm dimeter stinless steel wire cble. The distl cble strnds exited the tibil tunnel nteriorly nd were secured by split clmp mounted to the tibi. When inserted into the knee, the grft ws oriented such tht its wide dimension ws ligned with the wide dimension of the ntive PCL. The proximl bone block of the grft ws plced into n 11 mm dimeter cylindricl chmber within n luminum cnister fixed to the femorl lod cell; the xis of the chmber ws concentric with the xis of the lod cell. The grft ws pretensioned by pplying force to the cble strnds of the proximl bone block, which ws free to retrct proximlly within the chmber; constnt 25 N nterior force ws pplied to the tibi during pretensioning. The nterior tibil force ws pplied to estblish stndrd position of the tibi reltive to the femur s the grft ws pretensioned. This ssured tht none of the pplied pretension ws used to displce the tibi nteriorly from n unknown resting position (reltive to the femur). The circulr opening t the end of the chmber (through which the grft pssed) ws locted 5 mm nterior to center of the ntive PCL's femorl footprint; this simulted grft plcement t the pproximte loction of the nterolterl bundle of the PCL. A grft pretension ws found which reproduced intct AP lxity within 1. mm t 9" of knee flexion (lxity mtch pretension). nd AP lxity testing ws repeted t ll flexion ngles listed bove. The grft ws lwys preconditioned prior to determining the lxity mtch pretension by pplying four complete AP loding cycles to 2 N force. Next, resultnt force in the grft ws recorded using the femorl lod cell s the knee ws flexed from -So to 14" of flexion. Then series of constnt tibil loding tests were performed during knee flexion from -5" to 12". The tibil lodings pplied were 1 N posterior tibil force, 5 Nm vrus moment, 5 Nm vlgus moment, 5 N m internl torque, nd 5 Nm externl tibil torque. The grft ws retensioned to the lxity mtch pretension t the strt of ech of the test series. This ws done to correct for ny loss of grft pretension which occurred during the course of testing. Further detils of the constnt tibil loding tests cn be found in our prior publictions [I,1 I]. Once testing hd been completed with the centrl tunnel, the hole ws plugged with press-fit cylinder of high density polyurethne fom nd new tunnel ws drilled such tht its center ws 5 mm medil to the center of the old centrl tunnel t the sme distnce below the posterior mrgin of the tibil plteu. A new lxity mtch pretension ws determined, nd ll tests described bove were repeted. Finlly, the medil hole ws plugged with fom cylinder, new tibil tunnel ws drilled such tht its center ws 5 mm lterl to the center of the originl centrl tunnel, new lxity mtch pretension ws determined, nd ll tests were repeted finl time. The sme grft ws used for ll testing for given knee. For ech tunnel, the sme test protocol ws lwys used: the grft ws pretensioned, the AP test series ws performed, the grft ws retensioned, the constnt tibil loding test series ws performed. A two-wy nlysis of vrince (ANOVA) model with repeted mesures ws used to determine the significnce of differences between men AP lxities with centrl, medil, nd lterl tibil tunnels. Multiple pirwise comprisons between mens t specific knee flexion ngles were mde using the Student Neumn Keuls procedure. Similr ANOVA models (with pirwise comprisons) were used to compre grft forces between tunnel loctions for ech constnt tibil loding test. A one-wy ANOVA model ws used to compre lxity mtch pretensions between the three tunnel loctions. The level of significnce ws p <.5. Results The men lxity mtch pretension for the centrl tibil tunnel ws 47.2 N (SD 24. N) (Tble 1). Men lxity mtch pretension for the medil tibil tunnel ws 61. N (SD 27.7 N) (Tble I); this represented 13.8 N

3 K.L. Mrkolf et l. I Journl of Orthopedic Reserch 21 (23) Tble 1 Lxity mtch grft pretensions (men f SD) for three tibil tunnels Pssive Knee Flexion Tunnel Centrl tibil tunnel (C) Medil tibil tunnel (M) Lterl tibil tunnel (L) Lxity mtch pretension (N) 47.2 (24.) 61. (27.7) 52.3 (25.7) w centrl tibil tunnel T M vs. C sign. diff. (p <.4). M vs. L sign. diff. (p <.4). (29%) increse over the lxity mtch pretension for the centrl tunnel G. <.4). Men lxity mtch pretension for the lterl tunnel ws not significntly different thn tht for the centrl tunnel (Tble 1). The power of the test ws.9858 (lph =.5). With the centrl tibil tunnel, the men lxities were 9.8, 13.5, nd 7.3 mm t 9", 3", nd " of flexion respectively (Tble 2). Men lxities with centrl, medil, nd lterl tibil tunnels were not significntly different from ech other t ny knee flexion ngle (Tble 2). At " nd 3" of flexion, men lxities fter grft reconstruction were significntly greter thn corresponding intct knee mens for ll three tibil tunnel positions (Tble 2); these men lxity increses rnged between 1.1 nd 2.2 mm t ", nd between 1. nd 1.4 mm t 3". During pssive knee flexion with the centrl tibil tunnel, men grft force remined ner zero until pproximtely 4" of flexion, t which point it incresed to 121 N t 14" of knee flexion (Fig. 1). Men grft forces with the lterl tibil tunnel were not significntly different from those with the centrl tunnel (Fig. 1). Men grft forces with the medil tibil tunnel were significntly greter thn those with the centrl tunnel beyond 65" of knee flexion (Fig. 1): t 12" of flexion the men grft force increse ws 25 N. For 1 N pplied tibil force, men grft force with the centrl tunnel incresed from 12 N t -5" of flexion to 194 N t 12" of flexion. Men grft forces with medil nd lterl tunnels were not significntly different thn those with the centrl tunnel (Fig. 2). For 5 Nm vrus moment, men grft force with the centrl tunnel remined reltively low until pproxi- 5- z Fig. 1. Pssive knee flexion. Test curves of grft force vs. knee flexion ngle for the constnt tibil loding tests. Men curves re indicted by symbols t 5" increments for centrl, medil, nd lterl tibil tunnels. Portions of the knee flexion rnge for which men curves re significntly different (p <.5) re indicted: men curves which re not significntly different re indicted by n.s. 1 OON Posterior Tibi1 Force centrl tibil tunnel medil tibil tunnel lterl tibil tunnel VS. n.s. (ll) vs. n.s. (ll) > (>8deg.) Fig N posterior tibil force. Explntion is sme s in Fig. 1. mtely 4" of flexion where it incresed from 2 to 181 N t 12" of flexion (Fig. 3). Men grft forces with medil nd lterl tunnels were not significntly different thn those with the centrl tunnel (Fig. 3). These findings lso held for the 5 N m vlgus test condition, where the shpes of ll men curves were very similr to the Tble 2 Anterior-posterior knee lxities in mm (men i SD) for three tibil tunnels Condition Knee flexion ngle (der) Intct knee 1.3 (1.3) 12.4 (2.1) 1.7 (2.4) 9.5 (1.9) 1.5 (1.7) Centrl tibil tunnel (C) 8.4 (3.)' 13.5 (2.)' 11.3 (1.8): 9.8 (2.1) 11.3 (2.6)' Medil tibil tunnel (M) 9.5 (l.o)* 13.8 (1.9y 11.3 (1.6)* 9.8 (2.1) 1.2 (2.8) Lterl tibil tunnel (L) 9.5 (1.2)* 13.4 (1.8y 11.1 (1.8) 9.8 (2.1) 1.8 (1.7) C vs. M not sign. diff. (ll flexion ngles). C vs. L not sign. diff. (ll flexion ngles). M vs. L not sign. diff. (ll flexion ngles). 'Sign. diff. from intct (p <.5).

4 18 K.L. Murkolfet ul. I Journl of Orthopedic Reserch 21 (23) i 2 $ 2 z W LL 1 t Cc 5i Z 2 u 5 N-m Vrus Moment centrl tibil tunnel medil tibil tunnel lterl tibil tunnel VS. n.s. (ll) VS. n.s. (ll ) vs. n.s. (ll ) Fig N m vrus moment. Explntion is sme s in Fig. 1 3 z 2 - z w F loo 5 N-m Externl Tibi1 Torque centrl tibil tunnel medil tibil tunnel o lterl tibil tunnel vs. n.s. (ll) OQQQQQQQQ Fig N m externl tibil torque. Explntion is sme s in Fig. 1. corresponding men curves shown in Fig. 3. However, the grft force mgnitudes t 12" flexion for 5 Nm vlgus moment were pproximtely 32% less thn those shown for 5 Nm vrus moment. For 5 Nm externl tibil torque, men grft force with the centrl tunnel remined t pproximtely 13 N between -5" nd 4" of flexion, rising to 181 N t 12" of flexion (Fig. 4). Men grft forces with medil nd lterl tunnels were not significntly different thn those with the centrl tunnel (Fig. 4). These findings lso held for 5 N m of pplied internl torque, where the shpes of ll men curves were very similr to the corresponding men curves shown in Fig. 4. However, the grft force mgnitudes t 12" flexion for 5 Nm internl tibil torque were pproximtely 14"/ less thn those shown for 5 Nm externl tibil torque. Discussion In prior study from this lbortory [13], n 11 mm bone-ptellr tendon-bone grft tht ws pretensioned to mtch AP lxity t 9" of flexion restored norml AP lxities between " nd 9" of flexion; the men lxity mtch pretension ws 43 N. In tht study, the femorl tunnel ws drilled t the center of the PCL's femorl footprint nd the tibil tunnel ws drilled t the center of the PCL's tibil footprint (centrl tibil tunnel). In the present study, similr grft plced in femorl loction pproximting the PCL's nterolterl bundle restored intct knee (to within 1.1 mm) lxity between " nd 12" of knee flexion, with men lxity mtch pretension of 47 N. Men grft force mgnitudes were comprble between both studies for ll modes of testing with the exception of externl tibil torque, where men grft forces ner 9" flexion in the present study were somewht higher thn those of the prior study. Bch et l. [2] used mthemticl model of the knee to clculte chnges in ntive PCL forces resulting from medil-lterl vritions of 5. mm from the ntomicl tibil insertion of the ligment. In tht study, PCL force levels were clculted fter 5. mm posterior displcement of the tibi reltive to the femur. They found tht medil tunnel plcement incresed PCL forces for this loding condition t ll flexion ngles from " to 9", while lterl tunnel plcement decresed PCL forces over the sme rnge. For the loding condition of 1 N posterior tibil force, we found no significnt chnges in grft forces with medil or lterl grft plcement over this flexion rnge. It is not possible to directly compre results from these studies; their ntive PCL forces were clculted for fixed tibil displcement while our grft forces were mesured by pplying constnt posterior force of 1 N to the tibi. Hrner et l. [lo] used robotichniversl force-moment sensor testing system to indirectly mesure forces in the grft following single bundle PCL reconstruction. With 134 N posterior lod, they found in situ forces in the PCL rnged from 17 N t full extension to 85 N t 9" of flexion. These vlues were significntly lower thn those for the intct PCL the throughout rnge of knee flexion by 13 N t full extension to 44 N t 12" of flexion. It is difficult to mke direct comprisons between this study nd our current study becuse of the differences in testing methods. The only loding condition used by Hrner et l. ws 134 N posterior force while we used multiple loding conditions. Furthermore the mgnitude of their posterior force (134 N) differed from our 1 N posterior tibil force. There re severl experimentl limittions to our study. For ll reconstructions, the femorl tunnel opening ws rounded edge of luminum, rther thn rsped edge of bone. The geometry of the intersection of the tunnel with the internl contour of the femorl notch ws not completely duplicted with our cnister design. However, since the sme femorl cnister ws used for ll tibil tunnel plcements, this source of error would not be expected to influence our comprtive results.

5 K. L. Mrkolf'et l. I Journl of' Orthopedic Reserch 21 (23) Furthermore, it would be difficult to pply fetures of our experimentl protocol directly to the operting room environment. In this study, the mount of pretension tht ws pplied to ech grft ws sufficient to restore lxity to within 1 mm of tht for the intct knee t 9" of flexion. This mount of pretension ws unique for ech specimen nd the trget lxity for the intct knee ws known. In the operting room, the pre-injury lxity of the knee is unknown nd grft pretension nd knee lxity re not usully mesured. Our rtionle for pretensioning the grft t 9" flexion deserves specil mention. Prior biomechnicl studies hve shown tht t 9" of flexion, the PCL is the primry restrint to posterior tibil trnsltion [5,7,8]. At this flexion ngle, the PCL essentilly resists ll of n pplied posterior tibil force. A PCL grft functions in the sme mnner. Since the primry function of the grft is to resist posterior tibil force, it follows tht the PCL grft should be tensioned to restore posterior tibil trnsltion t flexion ngle tht grft is most functionl. If the grft were tensioned t flexion ngle where other secondry restrints were ctive, the lxity mtch pretension obtined would not only be ffected by the biomechnicl function of the grft, but lso by the vrible contributions of the secondry structures. To our knowledge, most published studies of PCL reconstruction refer to grft tensioning t 7-9" of flexion. In the present study, the centrl tunnel ws drilled through the center of the ntive PCL's tibil insertion (s viewed directly through posterior rthrotomy); medil nd lterl tunnels were referenced to this position. During surgery the tibil tunnel is normlly mde with the ssistnce of drill guide which is designed to position the guide tip pproximtely 1 cm below the tibil plteu; with some of the newer drill guides the superior-inferior position of the guide tip is djustble. However the superior-inferior position of ll drill guide tips cn be vried by tilting the guide reltive to the tibil plteu in the sgittl plne. Even though mny surgeons use n ccessory posterior rthroscopic portl to help ssure correct plcement of the guide tip, it cn still be difficult to visulize the ntomic insertion site of the PCL. Accurte plcement of the guide is dependnt on dequte visuliztion of the PCL insertion by the surgeon. Since loction of the centrl tunnel ws likely more ccurte in our study thn would be expected in clinicl prctice, our results represent "best cse" scenrio with respect to the gol of ntomicl tunnel plcement. Due to our repeted mesures design, ech specimen hd three seprte tunnels drilled in the tibi. The technique of plugging previously drilled tunnels with press-fit cylinders of high density polyurethne fom llowed multiple holes to be drilled without the guide pin nd drill deviting from the intended direction. The fom mteril drilled clenly nd produced uniform tunnels, even in res of prtil fom nd prtil bone. We intentionlly did not test vritions in tunnel position in the superior-inferior direction becuse mny commercilly vilble drill guides ssist with locting this coordinte fixed distnce below the surfce of the tibil plteu. Becuse the order of testing the vrious tunnel positions ws not rndomized, it is possible tht tissue desicction nd stretch-out of secondry restrints my hve influenced the results of this study. Vritions in tissue properties between ptellr tendon grfts could hve lso ccounted for some of the vribility in the results of this study. However, we believe tht these vribles hd miniml effect upon the overll conclusions of the study. Compred to the centrl tunnel, the medil tunnel produced higher grft forces beyond 65" of pssive knee flexion. With medil tunnel, the grft is positioned more verticlly in the frontl plne; this would theoreticlly result in shorter effective grft length between insertion points into the femur nd tibi. The shorter grft length could produce slightly higher effective grft stiffness, which could produce incresed grft forces s the knee ws moved through its kinemtic pthwy during the pssive flexionxxtension cycle. Another contributing fctor to higher grft forces with the medil tunnel could be the incresed lxity mtch pretension with this loction. The resons for this higher pretension re not immeditely obvious. One possible explntion reltes to impingement of the PCL grft with the ACL t 9" of flexion, which ws confirmed visully to vrying degrees in ll knee specimens. In generl, this impingement would be expected to decrese totl AP knee lxity. Moving the tibil tunnel medilly would tend to move the grft wy from the ACL nd reduce impingement, thereby incresing knee lxity. This would in turn require slightly higher PCL grft pretension to restore totl AP lxity to norml. However, the men pretension increse of 13.8 N with the medil tunnel does not fully ccount for grft force increses observed ner full knee flexion. While higher grft pretension with the medil tunnel could be fctor in the higher grft forces ner full flexion, it is probbly not the only fctor. It should be noted tht these grft forces were not higher t lower flexion ngles. Therefore, we believe there is lso seprte tunnel position effect which is most influentil ner full flexion. In ny cse, the mgnitude of the force increses with the medil tunnel (pproximtely 25 N t 12" of flexion) would not be expected to be importnt with respect to grft force levels expected in vivo. For exmple, Morrison [16] clculted the men pek force in the PCL during level wlking to be 329 N. As we hve reported in prior PCL grft reconstruction study from our lbortory [15], loss of grft pretension ws observed s the knee ws cycliclly

6 182 K.L. Murkolf et crl. I Journul of Orthopeilic Reseurch 21 (23) loded. For exmple, we found 3443% loss in initil grft pretension fter pplying 5 posterior tibil loding cycles (2 N) to the grft. We believe tht this is primrily due to viscoelstic chnges in the grft tissue, with possible contribution from chnges in the grft fixtion system. Since the present study employed repeted mesures experimentl design nd the sme grft ws plced in multiple tunnels, the grft ws pretensioned t the strt of ech test series to estblish n equl initil grft pretension for ech of the three tunnel positions. We did not specificlly record the mount of grft retensioning required to return to the lxity mtch pretension prior to ech test series. Although we did not mke specific mesurements, the grft pretensions tended to chieve stedy vlue fter repeted loding tests nd did not relx down to zero. Bsed upon the results of this study, we conclude tht surgicl errors in medil-lterl plcement of the tibil tunnel should be inconsequentil with respect to lxity of the reconstructed knee. Errors in lterl tunnel plcement would be preferble to plcing the tunnel medilly in terms of reducing grft force mgnitudes during pssive knee flexion beyond 65" of flexion. The reltively smll increse in lxity mtch pretension with the medilly plced tibil tunnel suggests tht higher grft pretension would be necessry to restore intct knee lxity if this surgicl error hs been mde. Acknowledgements The uthors would like to thnk Steven Jckson for his ssistnce in nlysis of the dt. The ptellr tendon llogrfts for this study were provided by the Musculoskeletl Trnsplnt Foundtion. No uthor or relted institution hs received ny finncil benefit from the reserch in this study. References [l] Bch BR. Grft selection for posterior crucite ligment surgery. Oper Tech Sports Med 1993; 1 : [2] Rch BR, Dlug DJ, Mikosz R, Andricchi TP, Seidl R. Force displcement chrcteristics of the posterior crucite ligment. Am J Sports Med 1992;2: [3] Uomberg BC, Acker JH, Boyle J, et l. The effect of posterior crucite ligment loss nd reconstruction of the knee. Am J Knee Surg 199;3: [4] Covey DC, Speg AA, Shermn GM. Testing for isometry during reconstruction of the posterior crucite ligment: Antomic nd biomechnicl considertions. Am J Sports Med 1996;24:74-6. [5] Fukubyshi T, Torzilli TA, Shermn MF. An in vitro biomechnicl evlution of nterior posterior motion of the knee. Tibi1 displcement. rottion, nd torque. J Bone Joint Surg 1982;64A: [6] Gllowy MT, Grood ES, Mehlic JN, et l. Posterior crucite ligment reconstruction: An in vitro study of femorl nd tibil grft plcement. Am J Sports Med 1996;24: Gollehon DL, Torzilli PL, Wrren RF. The role of the posterolterl nd crucite ligments in the stbility of the humn knee: A biomechnicl study. J Bone Joint Surg 1987;69A: Grood ES, Stowers SF, Noyes FR. Limits of movement in the humn knee: Effect of sectioning the posterior crucite ligment nd posterolterl structures. J Bone Joint Surg 1988;7A: Hrner CD, Hoher J. Current concepts: Evlution nd tretment of posterior crucite ligment injuries. Am J Sports Med 1998; 26: Hrner CD, Jnushek MA, Knmori A, Ygi M, Vogrin TM, Woo SL. Biomechnicl nlysis of double-bundle posterior crucite ligment reconstruction. Am J Sports Med 2;28: I4& 51. Lipscomb Jr AB, Anderson AA, Norwig ED, et l. Isolted posterior crucite ligment reconstruction: Long term results. Am J Sports Med 1993;21:49-6. Mrkolf KL, Burchfield DB, Shpiro MS, Dvis BR, Finermn CAM, Sluterbeck JL. Biomechnicl consequences of replcement of the nterior crucite ligment with ptellr ligment llogrft. Prt I: Insertion of the grft nd nterior-posterior testing. J Bone Joint Surg [Am] 1996;78: Mrkolf KL, Sluterbeck JR, Armstrong KL, Shpiro MS, Finermn GAM. A biomechnicl study of replcement of the posterior crucite ligment with grft, prt I: Isometry, pretension of the grft, nd nterior-posterior lxity. J Bone Joint Surg [Am] 1997;79: Mrkolf K L, Sluterbeck JR, Armstrong KL, Shpiro MS, Finermn CAM. A biomechnicl study of replcement of the posterior crucite ligment with grft, prt 11: Forces in the grft compred with forces in the intct ligment. J Bone Joint Surg [Am] 1997;79: McAllister DR, Mrkolf KL, Okes DA, Young C, McWillims J. A biomechnicl comprison of tibil inly nd tibil tunnel posterior crucite ligment reconstruction techniques: grft pretension nd knee lxity. Am J Sports Med 22;3(3): Morrison JB. Mechnics of the knee joint in reltion to norml wlking. J Biomech 197:3: Noyes FR, Brber-Westin SD. Posterior crucite ligment llogrft reconstruction with nd without ligment ugmenttion device. Arthroscopy 1994;1: Rcnelli JA, Drez Jr D. Posterior crucite ligment tibil ttchment ntomy nd rdiogrphic lndmrks for tibil tunnel plcement in PCL reconstruction. Arthroscopy 1994;1(5): Vn Dommelen BA, Floler PJ. Antomy of the posterior crucite ligment, review. Am J Sports Med 1989;17:24-9.

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