The progression of anterior translation after anterior cruciate ligament reconstruction in a caprine model.

Large post-operative anterior-posterior translations are frequently reported after quadruped anterior cruciate ligament (ACL) reconstructions. To determine when the translation increases occur and the mechanism responsible, we followed the anterior and posterior translation limits in 18 goat knees for six months. Reconstructions were performed using grafts 4 or 7 mm wide placed in initially tight or lax positions. The anterior and posterior translation limits at 50 N were monitored using Roentgen stereophotogrammetric analysis. Graft bone block stability and soft tissue segment lengths were also assessed. Large (> 2 mm) increases in anterior translation were noted in 71% of the subjects at two weeks, and in 88% at eight weeks. The translations in the lax and tight groups were indistinguishable after two weeks. Joints with wide grafts had less anterior translation compared to narrow grafts at all time periods, but were significant different only at 26 weeks. The posterior translation limit moved anteriorly over the 26 weeks. Eight of nine joints had stable graft bone markers and/or increases in graft soft tissue lengths. In conclusion, increased anterior translation occurred soon after ACL reconstruction, was associated with graft soft tissue changes, and appeared to be reduced by larger grafts. A post-surgical decrease in posterior translation limit was also observed.

Knee joint contact pressure decreases after chronic meniscectomy relative to the acutely meniscectomized joint: a mechanical study in the goat.

Several studies have shown that meniscectomy causes an immediate, acute increase in knee joint contact pressure and that changes in pressure distribution cause remodeling of bone and soft tissue. Presumably, this remodeling in turn affects contact pressures. This study tested the hypothesis that medial compartment contact pressure increases immediately after medial meniscectomy and then decreases with time. Supporting hypotheses regarding medial compartment contact area and lateral compartment pressures also were tested. Unilateral medial meniscectomy was performed on seven adult goats. Four or 8 months later, contact pressure and area were measured in vitro in the involved joints, as well as in the contralateral joints, before and after removal of the meniscus. The medial compartment pressures of the chronically meniscectomized joints were significantly less than those of the acutely meniscectomized paired joints but remained significantly greater than those of the intact joints. For the 4 and 8 month groups combined, the mean pressures of the acutely and chronically meniscectomized joints were greater than the pressures of the paired intact joints by 70 and 42%, respectively. The mean medial compartment contact areas of the acute and chronic joints were lower than those of the intact joints by 60 and 50%, respectively; mean lateral compartment pressures remained the same. This study indicates that joint remodeling reduces joint contact pressures. It also suggests that the effectiveness of a treatment to reduce pressure concentrations may be determined only by comparison, at the same postoperative time, of the pressure with that of the chronically meniscectomized joint, since pressures decreased with time without treatment.

Uniaxial tension inhibits tendon collagen degradation by collagenase in vitro.

Tendon structure is governed largely by factors regulating the anabolic and catabolic phases of tenocyte metabolism. Little is known about the mechanisms that regulate the synthesis, activation, and action of metalloproteinases, which are key enzymes in a multifactorial cascade controlling homeostasis of the extracellular matrix. In the present study, we investigated the effect of tension on collagenase-induced degradation of the tendon in vitro by assessing changes in structural and material properties measured during tensile failure tests. Devitalized right-left pairs of rabbit patella-patellar tendon-tibia units were maintained under culture conditions in the presence of 60 U/ml highly purified collagenase for 20 hours. One randomly selected unit from each animal was subjected to a tension that produced a constant 4% elongation or strain (n = 10); the contralateral unit served as a slack comparison (n = 10). In one series of experiments (immediate, n = 5), the tension was applied immediately prior to collagenase exposure. In a second series (delayed, n = 5), it was delayed for 4 hours to allow time for the collagenase to diffuse into the tendon. Additional devitalized and nonincubated units (n = 6) were used as normal controls. Collagenase exposure caused large decreases in stiffness and elongation to failure in slack units. This resulted in greater than 80% reductions in both maximum failure force and energy to failure. In contrast, the loaded unit in both experimental protocols had significantly greater stiffness than control units. In both the immediate and the delayed protocols, the loaded tendons had significantly higher stiffness and failed at significantly higher elongations and maximum forces than the slack tendons. Diffusion studies with and without tension showed the tension did not inhibit diffusion of collagenase into the tendon but did significantly decrease the water content from 64.6 to 57.8%. The data suggest that stresses and strains of the extracellular matrix may modify the kinetics of the bacterial collagenase-collagen interaction. Matrix stress and strain may be an important and overlooked factor that modulates the susceptibility of collagen to proteolytic degradation.

Cell alignment is induced by cyclic changes in cell length: studies of cells grown in cyclically stretched substrates.

Many types of cells, when grown on the surface of a cyclically stretched substrate, align away from the stretch direction. Although cell alignment has been described as an avoidance response to stretch, the specific deformation signal that causes a cell population to become aligned has not been identified. Planar surface deformation is characterized by three strains: two normal strains describe the length changes of two initially perpendicular lines and one shear strain describes the change in the angle between the two lines. The present study was designed to determine which, if any, of the three strains was the signal for cell alignment. Human fibroblasts and osteoblasts were grown in deformable, rectangular, silicone culture dishes coated with ProNectin, a biosynthetic polymer containing the RGD ligand of fibronectin. 24 h after plating the cells, the dishes were cyclically stretched at 1 Hz to peak dish stretches of 0% (control), 4%, 8%, and 12%. After 24 h of stretching, the cells were fixed, stained, and their orientations measured. The cell orientation distribution was determined by calculating the percent of cells whose orientation was within each of eighteen 5 degrees angular intervals. We found that the alignment response was primarily driven by the substrate strain which tended to lengthen the cell (axial strain). We also found that for each cell type there was an axial strain limit above which few cells were found. The axial strain limit for fibroblasts, 4.2 +/- 0.4%, (mean +/- 95% confidence), was lower than for osteoblasts, 6.4 +/- 0.6%. We suggest that the fibroblasts are more responsive to stretch because of their more highly developed actin cytoskeleton.

Subject variation in caprine anterior cruciate ligament reconstruction.

We studied the subject and treatment contributions to anterior cruciate ligament (ACL) reconstruction biomechanics by reexaming the results of two bilateral reconstruction studies. Bilateral reconstruction allows a comparison between treatments exposed to the same subject related healing factors. The studies examined the effects of gamma irradiation and the effects of initial graft size and initial graft laxity. In both studies different treatments were applied to contralateral limbs. We found that the subject was the best predictor of outcome, while the surgical treatments had little influence on outcome. There was a large variation between subjects despite similar treatments, and little difference between contralateral limbs despite different surgical treatments. At 26 weeks, the graft cross sectional area and modulus were most strongly influenced (p < 0.002) by the subject. We interpret this as a subject related factor is regulating the quantity and quality of the healing tissue. Potential sources of subject related factors include the subject's pre-operative condition, the activity during the post-operative period, and an intrinsic biologic response. By better understanding the source of subject variation, more successful and consistent ACL reconstructions might be achieved.

Primary and coupled motions in the intact and the ACL-deficient knee: an in vitro study in the goat model.

Quadrupeds are commonly used as animal models to study healing of anterior cruciate ligament (ACL) reconstructions. While rabbits, dogs, goats, and sheep have been used, goats and sheep are increasingly being employed because of the larger joint size that facilitates surgery, ease of availability, and lower expense to maintain in the farm environment. In spite of this, little is known about the function of the ACL in controlling primary and coupled motions in the quadruped. We report here on the measurements of these motions in goats, with the application of anterior-posterior forces, varus-valgus moments, and internal-external moments in the intact and ACL-deficient knee. Sectioning the ACL caused significant increases in primary anterior translation, and in varus-valgus and internal rotations. The increases in anterior translation were similar in amount and dependence on flexion angle to those seen in human knees. The increase in varus averaged 7 degrees and did not depend on flexion angle, whereas the increase in valgus was significant only in the flexed knee. The increases in internal tibial rotation were greatest in extension, whereas the increases in external rotation were small and independent of flexion angle. When the ACL was cut, coupled internal rotation increased with an anterior force as well as a valgus moment. Large increases were seen in coupled anterior translation with the application of varus and valgus moments, whereas smaller increases were seen with internal and external moments. These findings demonstrate that the ACL restrains multiple motions in the goat knee. This study also provides baseline data for future studies of ACL reconstruction.

Anterior cruciate ligament replacements: a mechanical study of femoral attachment location, flexion angle at tensioning, and initial tension.

We examined three surgical variables that affect the ability of an anterior cruciate ligament replacement to restore the limit of anterior tibial translation. These were the placement site of the substitute on the femur, the initial tension applied to the replacement, and the flexion angle of the knee at the time of tensioning. An anterior load of 100 N was applied to the tibia. As the knee was flexed, we measured the tensile force in the substitute and the anteroposterior position of the femur relative to the tibia. Placement largely determined whether the force in the replacement increased or decreased with flexion. Placement also largely determined whether the tibia moved anteriorly or posteriorly with flexion compared to its position in the intact knee. The initial tension and the flexion angle at tensioning affected the magnitude of force in the substitute and the magnitude of the change in AP position. They did not affect how force and AP position changed with flexion. Greater increases in force and greater posterior shifts in tibial position were produced by changing the flexion angle at tensioning from 0 degrees to 30 degrees than by increasing the initial tension from 22 to 44 N.

Mechanical properties of primate vascularized vs. nonvascularized patellar tendon grafts; changes over time.

Mechanical properties of patellar tendon autografts used to replace the anterior cruciate ligament (ACL) in the cynomolgus monkey were measured at four time periods up to 1 year. The ACL was replaced in each knee with the medial half of the patellar tendon: as a vascularized graft (VG) on one side and as a nonvascularized or free graft (FG) on the other. Postoperative care consisted of 4 weeks of cast immobilization at 30 degrees flexion followed by unrestricted activity in a large cage. Both grafts showed low stiffness and maximum force at 7 weeks (24% and 16% of ACL control values, respectively), increasing to 57% of control ACL stiffness and 39% of control maximum force by 1 year. Corresponding material properties, modulus and maximum stress, also increased over time, but at 1 year were only 34% and 26% of ACL values, respectively. The results indicate that retaining vascularity does not prevent significant reduction in graft properties that occur postoperatively, nor does it accelerate the return in strength and stiffness. Tissue stiffness, which returns earlier than maximum force and joint anteroposterior (AP) force displacement data, should be routinely reported in any healing study. Finally, in studies of this kind, the large variation in the results makes sampling only one or two animals from each time period unreliable.

Effects of gamma irradiation on the initial mechanical and material properties of goat bone-patellar tendon-bone allografts.

The effects of 60Co gamma irradiation on the initial mechanical properties of the composite bone-patellar tendon-bone unit (CU) and the tendon midsubstance (TM) were studied. Frozen specimens were exposed to either 2 or 3 Mrad of gamma irradiation. Paired frozen specimens served as intraanimal controls. Treatment effects on the CU were assessed using four mechanical parameters. Effects on the TM were assessed using four material parameters measured using an optical surface-strain analysis system. The maximum force and strain energy to maximum force of the composite unit were significantly reduced 27% and 40%, respectively, after 3 Mrad of irradiation (p less than .05). Mechanical properties of the CU were not significantly altered, however, following 2 Mrad of irradiation. Based on individual paired contrasts between treatment and control, significant differences were also found in the material properties of the tendon midsubstance. The maximum stress, maximum strain, and strain energy density to maximum stress were significantly reduced following 3 Mrad, but not 2 Mrad, of irradiation. The results provide important "time zero" material property data, which will be useful for later anterior cruciate ligament reconstruction studies using irradiated allograft patellar tendons in the goat model and other animal models as well.

The effects of graft width and graft laxity on the outcome of caprine anterior cruciate ligament reconstruction.

We studied how initial graft size and initial graft laxity affected the biomechanics of anterior cruciate ligament (ACL) reconstruction at six months. Sixteen goats had bilateral reconstructions staged eight weeks apart. Autografts 4 and 7 mm wide were taken from the central patellar tendon (PT). Lax grafts were created by adding 4 mm slack to the graft before fixing. We reconstructed each joint using a combination of width and laxity treatments. Both factors were changed for the contralateral joint and all combinations appeared with equal frequency. At six months we measured the joint extension limit, anterior-posterior (AP) translation, and osteoarthritic changes. The grafts were then tested to failure to determine their mechanical properties. After six months the difference in initial treatments had disappeared: there was no difference in graft cross-section due to the different initial widths and there was no difference in joint AP translation due to the initial graft laxity. We did observe that wide grafts were associated with a block to extension, decreased joint AP translation, and increased articular cartilage damage and osteophyte formation. While AP translation was reduced, it was correlated with decreased extension, possibly indicating an increase in scar tissue formation rather than a more functional graft. Neither graft width nor graft laxity produced differences in any graft mechanical properties. This suggests that the use of larger grafts to prevent increased AP translation has undesirable complications. Ultimately, we conclude that neither of these surgical treatments strongly affects the biomechanical result of caprine ACL reconstruction.

Biomechanics of fascia lata ligament replacements: early postoperative changes in the goat.

Mechanical properties of fascia lata autografts used to replace the anterior cruciate ligament (ACL) in the goat were measured at 0, 2, 4, and 8 weeks after surgery. The ACL was replaced in the right knee of 50 animals divided equally into two groups according to graft fixation technique: (a) two smooth staples at each end, with the tissue pulled back toward the joint over the first staple and (b) reinforced fixation with a spiked bushing placed through the tissue and a 3-cm-long flat polypropylene braid sutured to each end of the graft. Eleven unoperated contralateral knees were tested as controls. All statistically significant effects of the reinforced versus staple fixation were observed at 0 weeks, with the reinforced group showing less anteroposterior (AP) translation of the joint and greater maximum force and stiffness of the femur-graft-tibia units. The reinforced group had increased AP translation and decreased strength and stiffness by 2 weeks after surgery. Increased AP translation resulted primarily from increases in the low-stiffness region of the force-displacement curve (primary AP translation) and to a lesser extent from increased translation in the high-stiffness region (secondary anterior translation). Failures at 0 weeks with the reinforced fixation occurred at the bushing or end of the reinforcing braid, while all but one of the later failures occurred in the tissue mid-substance. In the staple group, maximum force was greater at 8 weeks than at 0 weeks, as the failure locations changed from the fixation to the tissue mid-substance.(ABSTRACT TRUNCATED AT 250 WORDS)

The correlation between anterior-posterior translation and cross-sectional area of anterior cruciate ligament reconstructions.

Total anterior-posterior translation is commonly used to assess the integrity of the cruciate ligaments and the success of reconstructive surgery. The purpose of this study was to determine, after surgical reconstruction of the anterior cruciate ligament with a biological graft, if total anterior-posterior translation correlated with graft length, cross-sectional area, or mechanical properties. These factors were investigated by analyzing data from three previous studies. These studies involved replacement of the anterior cruciate ligament in cynomolgus monkeys and goats, with free and vascularized patellar tendon autografts and both patellar tendon and anterior cruciate ligament allografts. Data were available at time periods of 6 and 12 months after surgery. We found statistically significant inverse correlations between the amount of anterior-posterior translation and cross-sectional area of a graft at the time of sacrifice. The Pearson correlation coefficients ranged from -0.966 (p < 0.002) to -0.830 (p < 0.05). We hypothesize that these correlations result from the following mechanism: the increased anterior translation reflects a slack graft; a slack graft is stress shielded by other structures about the knee; the reduced in vivo stresses on the graft modulate cellular metabolism in a way that over time produces a small cross-sectional area.

Effect of tibial attachment location on the healing of the anterior cruciate ligament freeze model.

We studied the healing response of a devitalized anterior cruciate ligament to a treatment of initial anterior-posterior joint translation in goats. Devitalization and devascularization were achieved by five successive freeze-thaw cycles. Anterior-posterior translation was surgically altered by an osteotomy of the tibial attachment of the devitalized ligament and its reattachment either in the anatomical position or in a position 5 mm posterior. Six weeks after the first surgery, the same procedure was performed on the contralateral limb, except that the ligament was reattached in the alternate position. Six months after the initial surgery, femur-anterior cruciate ligament-tibia specimens were tested to determine their structural and mechanical material properties. Anatomic ligament placement resulted in reduced anterior-posterior translation (p < 0.05) and greater anterior joint stiffness (p < 0.05). Maximum load (p < 0.05) and ligament stiffness (p < 0.01) also were greater for the anatomically placed anterior cruciate ligaments. The maximum load for anatomically placed ligaments averaged 1.625 +/- 211 N (SEM). The strength of the posteriorly placed anterior cruciate ligament, 895 +/- 164 N was similar to results of historical anterior cruciate autograft reconstructions. Ligament failure occurred near the tibial insertion in the posteriorly placed ligaments more often than in the anatomically placed ligaments (four of five times compared with one of five times). Ligament failure near the tibial insertion occurred with lower mean maximum load than failure at the midsubstance or by bone avulsion (796 compared with 1.592 N: p < 0.05). These data support the hypothesis that ligament laxity is important to the healing and remodeling of anterior cruciate ligament grafts.

Advances in the understanding of knee ligament injury, repair, and rehabilitation.

Knee injuries continue to present a complex set of clinical problems. The answers to these problems have recently been redefined by the application of sophisticated biomechanical research methods to the study of knee ligaments and joint function. This manuscript reviews contributions which our laboratory has made to the understanding of knee injury, highlighting those research findings which form the basis for our clinical treatment of knee ligament injuries. High strain-rate techniques for studying knee ligament failure have replaced the previous low strain-rate methods and distinguish the failure mechanism of ligaments from that of bone. Ligament function is now further defined by measuring the restraining force provided by specific ligaments, adding to the information provided by cutting studies. The development of the 6-degrees-of-freedom concept and the instrumented kinematic chain now permit precise analysis of joint position, motion, and laxity. Biomechanical evaluation of intra-articular anterior cruciate ligament substitution has emphasized the importance of selection of a high-strength graft material, meticulous surgical technique with attention to graft vascularity, precise location of graft fixation sites, judicious adjustment of graft tension, post-operative protection during tissue remodelling, and a carefully conceived rehabilitation program. Newer biomechanical research methods have provided a sound scientific foundation on which to base clinical decisions concerning the care of knee ligament injuries.

The strength of the anterior cruciate ligament in humans and Rhesus monkeys.

The mechanical properties of anterior cruciate bone-ligament-bone specimens from humans and rhesus monkeys were determined in tension to failure under high strain-rate conditions. The age range of the human specimens was from sixteen to eighty-six years. The values fro human specimens obtained from young adults with regard to elastic modulus, ultimate tensile stress, and strain energy to failure were approximately two to three times those for specimens from humans in the sixth decade and older. The major mode of failure was ligament disruption in the specimens from young adult humans and avulsion of bone beneath the ligament insertion site in the specimens from older humans. The difference in mode of failure correlated with histological observations of decreased bone mass at the site of ligament attachment in the specimens from older humans. Rhesus monkey specimens had higher values for elastic modulus, failure stress, and strain energy. Significant reductions in strength and stiffness properties of ligament units were shown to occur with advancing age to a greater degree than expected. All experiments in which specimens from older human cadavera are used should be interpreted with caution when the results are applied to mechanisms of ligament failure for younger or athletic individuals.

Cruciate ligament prosthesis: strength, creep, and fatigue properties.

The mechanical properties of the Richards polyethylene ligament implant were studied and compared with the strength of human cruciate ligament preparations. The implant yields and plastically deforms at a force of 420 newtons (ninety-four pounds) and approximately 10 per cent elongation when tested at a strain rate of 100 per second. This is one-fourth the average tensile strength of the human anterior curciate ligament preparations. When tested at a strain rate of 1 per cent per second the implant's yield-point force was lowered by 15 per cent. The implant exhibits considerable viscoelastic behavior and will progressively elongate under repetitive loads when insufficient time is allowed for it to return to its original length. In bending, the implant did not fail after eighty million stress reversals (forty million revolutions) when tested while immersed in saline solution at body temperature. The tests indicate that the tensile strength of the implant is low in comparison with both the strength of human preparations and estimates of actual in vivo functional loads. We conclude that caution is required in the use of this implant.

Limits of movement in the human knee. Effect of sectioning the posterior cruciate ligament and posterolateral structures.

We applied specific forces and moments to the knees of fifteen whole lower limbs of cadavera and measured, with a six degrees-of-freedom electrogoniometer, the position of the tibia at which the ligaments and the geometry of the joint limited motion. The limits were determined for anterior and posterior tibial translation, internal and external rotation, and varus and valgus angulation from zero to 90 degrees of flexion. The limits were measured in the intact knee and then the changes that occurred with removal of the posterior cruciate ligament, the lateral collateral ligament, the popliteus tendon at its femoral attachment, and the arcuate complex were measured. The cutting order was varied, allowing us to determine the changes in the limits that occurred when each structure was cut alone and the amount of motion of the joint that was required for each structure to become taut and to limit additional motion when the other supporting structures had been removed. Removal of only the posterior cruciate ligament increased the limit for posterior tibial translation, with no change in the limits for tibial rotation or varus and valgus angulation. The additional posterior translation was least at full extension and increased progressively, reaching 11.4 millimeters at 90 degrees of flexion. The progressive increase in posterior translation with flexion was apparently due to slackening of the posterior portion of the capsule, as the translation nearly doubled when the posterolateral structures subsequently were removed. Removal of only the posterolateral extra-articular restraints increased the amount of external rotation and varus angulation. The average increase in external rotation depended on the angle of flexion; it was greatest at 30 degrees of flexion and decreased with additional flexion. At 90 degrees of flexion, the intact posterior cruciate ligament limited the increase in external rotation to only 5.3 degrees, less than one-half of the 13.0-degree increase that occurred at 30 degrees of flexion. Subsequent removal of the posterior cruciate ligament markedly increased external rotation at 90 degrees of flexion, resulting in a total increase of 20.9 degrees. The limit for varus angulation was normal as long as the lateral collateral ligament was intact. When the lateral collateral ligament was cut, the limit increased 4.5 degrees (approximately 4.5 millimeters of additional joint opening) when the knee was partially flexed (to 15 degrees).(ABSTRACT TRUNCATED AT 400 WORDS)

Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.

Virtually all types of collagenous tissues have been transferred in and around the knee joint for intra-articular and extra-articular ligament reconstructions. However, the mechanical properties (in particular, strength) of such grafts have not been determined in tissues from young adult donors, where age and disuse-related effects have been excluded. To provide this information, we subjected ligament graft tissues to high-strain-rate failure tests to determine their strength and elongation properties. The results were compared with the mechanical properties of anterior cruciate ligaments from a similar young-adult donor population. The study indicated that some graft tissues used in ligament reconstructions are markedly weak and therefore are at risk for elongation and failure at low forces. Grafts utilizing prepatellar retinacular tissues (as in certain anterior-cruciate reconstructions) and others in which a somewhat narrow width of fascia lata or distal iliotibial tract is utilized are included in this at-risk group. Wider grafts from the iliotibial tract or fascia lata would of course proportionally increase ultimate strength. The semitendinosus and gracilis tendons are stronger, having 70 and 49 per cent, respectively, of the initial strength of anterior cruciate ligaments. The bone-patellar tendon-bone graft (fourteen to fifteen millimeters wide, medial or central portion) was the strongest, with a mean strength of 159 to 168 per cent of that of anterior cruciate ligaments. Patellar tendon-bone units, based on grip-to-grip motions, were found to be three to four times stiffer than similarly gripped anterior cruciate ligaments, while gracilis and semitendinosus tendon preparations had values that were nearly identical to those of anterior cruciate ligaments.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries.

In a prospective study, all injured knees that had traumatic hemarthrosis and absent or negligible instability on clinical examination underwent arthroscopy and examination under anesthesia. Eighty-five knees (eighty-three patients) were examined over a 125-week period. Some degree of disruption of the anterior cruciate ligament was found in sixty-one (72 per cent) of the knees (a partial tear in 28 per cent and a complete tear in 44 per cent), frequently associated with an injury of varying severity to other joint structures. These included minor ligament sprains without laxity in 41 per cent, a major associated ligament injury in 21 per cent, meniscal tears in 62 per cent (partial in 30 per cent and complete in 70 per cent), and a femoral chondral fracture or surface defect in 20 per cent. A popping sensation at injury occurred in 33 per cent of knees with a normal anterior cruciate ligament and in 36 per cent of those with a disruption. One-third of the knees had no to slight pain at the time of injury. The anterior drawer test without anesthesia was positive in only 24 per cent of the knees with a torn anterior cruciate ligament. We concluded that: (1) a traumatic hemarthrosis indicates a significant knee injury; (2) examination under anesthesia plus arthroscopy allows a more accurate diagnosis of injury to joint structures; and (3) such data are required for a rational treatment program to be outlined.

Biomechanics of the knee-extension exercise. Effect of cutting the anterior cruciate ligament.

UNLABELLED: We conducted this study to determine the effective moment arm of the knee extensor mechanism and the conditions under which the anterior cruciate ligament is loaded during knee-extension exercises. The moment arm was calculated from measurement of the quadriceps force required to extend the knee with and without resistive weights placed at the foot, the leg weight, and the location of its center of gravity. Changes in three-dimensional joint motion after the anterior cruciate ligament was removed were considered to be an indication that the ligament was loaded. The quadriceps force rose during the initial phase of knee extension and remained nearly constant at an average value of 177 newtons between 50 and 15 degrees. With extension past 15 degrees it rose rapidly, reaching an average of 350 newtons at zero degrees of extension, and continued to increase with hyperextension. The addition of thirty-one newtons (seven pounds) at the foot approximately doubled the quadriceps force that was required to extend the knee. The effective moment arm of the extensor mechanism increased with knee extension, peaked at approximately 20 degrees, and rapidly decreased with further extension. No change was found in the quadriceps force or its effective moment arm when the anterior cruciate ligament was sectioned except in hyperextension, where the quadriceps force decreased in two of five specimens. There was, however, an increased anterior tibial displacement in the range of 30 degrees to full extension, suggesting that the anterior cruciate ligament is loaded in that flexion arc. CLINICAL RELEVANCE: This study demonstrates that very large quadriceps forces are required to accomplish the last 15 degrees of extension during leg-raising exercises, typically twice those required to reach 30 degrees of flexion. The large forces that are required to obtain full extension explain why an extensor lag occurs with quadriceps weakness even though a full passive range of motion is possible. Since thirty-one newtons (seven pounds) of resistive weight added at the foot approximately doubles the quadriceps forces required to extend the leg alone, using such weights can produce very large quadriceps forces and concurrent patellofemoral and tibiofemoral contact forces. Because the quadriceps force increases little as the leg is extended from 50 to 15 degrees, in patients with patellofemoral chondroses for whom a full range of joint motion is not desired, quadriceps exercises can be limited to the amount of extension without decreasing quadriceps force.(ABSTRACT TRUNCATED AT 400 WORDS)