Two-bundle posterior cruciate ligament reconstruction: how bundle tension depends on femoral placement

Clinically, one-bundle posterior cruciate ligament reconstructions frequently result in the return of abnormal posterior translation. We hypothesized that the return of posterior translation is caused by a nonuniform distribution of load among the graft fibers. The purpose of the present study was to determine how the femoral attachment location of the second bundle of a two-bundle posterior cruciate ligament reconstruction affects the anterior bundle tension and the load distribution between the graft bundles.

One and two-bundle posterior cruciate ligament reconstructions (one one-bundle type and three two-bundle types) were performed in nineteen cadaveric knees. The grafts were tensioned to restore posterior translation to within +/-1 mm of that of the intact knee at 90 degrees of flexion while a 100-N posterior force was applied to the proximal part of the tibia. For each reconstruction, the total graft tension was a minimum of 2.3 times larger than the applied posterior force. Bundle tension and knee motions were measured as the knee was cycled from 5 degrees to 120 degrees of flexion while a 100-N posterior force was applied. Analysis of variance was used to compare the four reconstructions, and post hoc testing was performed with use of Fischer's protected least significant difference method.

Two-bundle reconstructions involving a middle-distal or middle-middle second bundle significantly reduced the tension in the anterior bundle in comparison with the tension in the one-bundle (anterior-distal) reconstruction. The peak anterior-bundle tensions with the middle-distal and middle-middle second bundles were 43% and 37% less than the peak bundle tension for the one-bundle reconstruction (p < 0.001 and p = 0.002, respectively). With the exception of the average bundle tension, the tension parameters calculated for the middle bundle decreased as the distance from the articular cartilage increased. The peak tensions for the middle-middle and middle-proximal bundles were 32% and 61% less than that for the middle-distal bundle (p = 0.028 and p = 0.001, respectively).

The femoral position of the second bundle significantly affected the tension in the anterior bundle and the load distribution. A second bundle placed in a middle or distal position resulted in a significant reduction in anterior bundle tension and in cooperative load-sharing (with the bundles functioning together). A proximal second bundle resulted in reciprocal loading (with one bundle functioning in flexion and one in extension), but the tension in the anterior bundle was not different from the tension in the one-bundle reconstruction.