Cadaveric Study Comparing the Biomechanical Properties of Grafts Used for Knee Anterolateral Ligament Reconstruction

doi:10.1016/j.arthro.2016.03.004

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 32, Issue 11, November 2016, Pages 2288-2294

https://doi.org/10.1016/j.arthro.2016.03.004 Get rights and content

Purpose

To measure the biomechanical properties (maximum load, stiffness, and elongation) of the anterolateral ligament (ALL), gracilis, and iliotibial band (ITB) within the same subject.

Methods

Thirteen unpaired knees were used (7 women, 6 men). The donors had a mean age at death of 54 years (range: 37 to 70 years). The mechanical properties of two types of ALL grafts were evaluated: ITB and two-strand gracilis. The mechanical properties of ALL were also measured. Validated methods were used to perform the tensile tests to failure and to record the results. Student's t-test was used to compare the various samples.

Results

The maximum load to failure was 141 N (±40.6) for the ALL, 200.7 N (±48.7) for the gracilis, and 161.1 N (±27.1) for the ITB. Only the gracilis had a significantly higher failure load than ITB and ALL (P = .001 and P = .03). The stiffness was 21 N mm⁻¹ (±8.2) for the ALL, 131.7 N mm⁻¹ (±43.7) for the gracilis, and 39.9 N mm⁻¹ (±6) for the ITB. The elongation at failure was 6.2 mm (±3.2) for the ALL, 19.9 mm (±6.5) for the gracilis, and 20.8 mm (±14.7) for the ITB.

Conclusions

The gracilis had the highest maximum load to failure. The ITB's mechanical properties most closely resemble those of the ALL.

Clinical Relevance

The biomechanical properties of each potential ALL graft can be factored in when deciding which type of graft to use.

Section snippets

Methods

Fifteen fresh-frozen cadaver knees (8 women, 7 men) were obtained from the pathology department of the Université Paul Sabatier (Toulouse, France). The donors had a mean age at death of 54 years (range: 37 to 70 years). The cadavers were stored at 4°C. The 15 cadaver knees were evaluated for signs of arthritis and restrictions by the lead author (E.C.). Any knees meeting one of the following exclusion criteria were not used: wounds or macroscopic signs of intra-articular lesions (Outbridge >

Results

The ALL had an average maximum load to failure of 141 N (range: 90 to 210 N). Its stiffness and elongation at failure were 21 N mm⁻¹ (range: 9 to 34 N mm⁻¹) and 6.2 mm (range: 1.1 to 10.5 mm), respectively. The ALL failed mid-substance in all the specimens. Table 1 summarizes the biomechanical properties of the ALL, gracilis, and ITB.

Discussion

Our hypothesis was confirmed: when the gracilis and ITB are prepared in the configuration used for LET, they have a higher maximum tensile load than the ALL. This difference was statistically significant for the gracilis. A two-strand gracilis graft had a significantly higher maximum load at failure and stiffness than the ALL.

Our results are consistent with previously published results. For the ALL, the average maximum load of 141 N (±40 N) and average stiffness of 21 N mm⁻¹ (±8.2) found in our

Conclusions

The gracilis had the highest maximum load to failure. The ITB's mechanical properties most closely resemble those of the ALL.

Acknowledgment

The authors wish to thank Joanne Archambault, Ph.D., for the editorial assistance provided during the preparation of this manuscript.

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The mechanical properties of the gracilis halves and iliotibial band were significantly different from anterolateral ligament, except for hysteresis and dynamic creep, respectively. Our findings showed that the gracilis halves may be a more appropriate graft choice for anterolateral ligament reconstruction due to its low energy dissipation and permanent deformation under dynamic loads.
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The CFL, CL and ACaL-ITCL show significant differences in their intrinsic mechanical properties. Both the CFL and CL are more compliant ligaments and seem to be involved in the development of subtalar instability. Based on the material properties, a gracilis tendon graft seems more appropriate than a synthetic ligament to reconstruct a CL or CFL. A partial rupture was the most commonly seen injury pattern in all ligaments. A fibular avulsion of the CFL was only rarely seen. The injury patterns need further investigation as they are important to optimize diagnosis and treatment.
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Because of these limitations, augmenting with the sartorius may provide a more reliable method in achieving a larger diameter graft, particularly in patients at higher risk of a small-diameter autograft, such as patients with shorter statures and females.19,45 Loading tendons to failure in tension has been performed at variable maximum displacement rates, ranging from.16 to 100 mm/s.9,33,37,39,46-50 In 1976, Kennedy and Noyes were among the first to use the modern-day servohydraulic testing machine to evaluate the ultimate load to failure of cadaveric ligaments.47,51 Kennedy reported the viscoelastic properties of biological structures change as the loading rate is increased and that the ultimate load to failure increases with the rate, which led to Noyes and Butler to introduce a loading rate of 100% elongation length per second in an attempt to simulate the fast strain-rate conditions in accidents with a maximum rate of 57.8 mm/s reported for the patellar tendon.39,46,47
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Four-strand and five-strand hamstring tendon grafts were harvested from matched cadaveric knees (mean age: 81.6 ± 9.8). These matched grafts were biomechanically tested using a MTS servohydraulic test system at a rate of testing representative of physiologic tears. The mean diameter, cross-sectional area, and ultimate load to failure were quantified and compared with a one-sided, paired Student’s t-test. A P < .05 was considered statistically significant.
The mean diameter of the five-strand graft was significantly larger than the four-strand graft (9.30 ± .84 mm vs 8.10 ± .42 mm; P = .002). The average ultimate load to failure of the five-strand graft was 65.3% higher than the four-strand graft (2984.05 ± 1085.11 N vs. 1805.03 ± 557.69 N; P = .009) and added 14.8% to the diameter of the four strand ST-G autograft.
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: The authors report that they have no conflicts of interest in the authorship and publication of this article.

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Original ArticleCadaveric Study Comparing the Biomechanical Properties of Grafts Used for Knee Anterolateral Ligament Reconstruction

Purpose

Methods

Results

Conclusions

Clinical Relevance

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgment

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Effectiveness of reconstruction of the anterior cruciate ligament with quadrupled hamstrings and bone-patellar tendon-bone autografts: An in vivo study comparing tibial internal-external rotation

Am J Sports Med

Prospective analysis of failure rate and predictors of failure after anatomic anterior cruciate ligament reconstruction with allograft

Am J Sports Med

Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction

Am J Sports Med

Biomechanical Analysis of simulated clinical testing and reconstruction of the anterolateral ligament of the knee

Am J Sports Med

Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic single-bundle anterior cruciate ligament reconstructions

Am J Sports Med

Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults

Cochrane Database Syst Rev

A meta-analysis of stability after anterior cruciate ligament reconstruction as a function of hamstring versus patellar tendon graft and fixation type

Arthroscopy

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Knee Surg Sports Traumatol Arthrosc

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Bone Joint J

The anterolateral ligament: An anatomic, radiographic, and biomechanical analysis

Am J Sports Med

The biomechanical function of the anterolateral ligament of the knee

Am J Sports Med

Original Article
Cadaveric Study Comparing the Biomechanical Properties of Grafts Used for Knee Anterolateral Ligament Reconstruction