The effect of graft tensioning in anatomic 2-bundle ACL reconstruction on knee joint kinematics

Recently, double bundle ACL reconstruction, in which the two bundles thought to have different effects on knee kinematics are reconstructed separately, is widely believed to more favorably restore normal knee kinematics than conventional single bundle ACL reconstruction. However, rotational kinematics during physiological movement after double bundle reconstruction has rarely been tested. The purpose of this study was to measure the kinematics of the ACL deficient and reconstructed knees using two different tensioning conditions in double bundle reconstruction, and to examine the effects of each graft on knee kinematics. Six cadaveric knees were used. Six degrees-of-freedom of knee kinematics and the tension of each graft were monitored during simulated knee extension with the ACL intact, resected, and reconstructed under two different tensioning conditions: 50 N on anteromedial bundle and 0 N on posterolateral bundle (AM-favored condition); 0 N on anteromedial bundle and 50 N on posterolateral bundle (PL-favored condition). Tibial translation: After ACL reconstruction, the tibia overcorrected posteriorly in both conditions. Such an overcorrection in the AM-favored condition was larger than in the PL-favored condition. Tibial rotation: The tibia was significantly externally rotated after ACL reconstruction at a low flexion angle in both conditions. However, at a high flexion angle, tibial external rotation was shown only in the AM-favored condition. Graft tension: While total tensions were similar between the two conditions, the AM bundle shared more tension in the AM-favored condition than in the PL-favored condition. A total of 50 N of tension force was assumed to be excessive for normalizing knee kinematics at a low flexion angle even if double bundle reconstruction was used. Additionally, the AM-favored tensioning reconstruction made the tibia rotate externally and translate posteriorly even at a high flexion angle. Further research is needed to normalize knee kinematics after ACL reconstruction, however it is recommended that a moderate tensioning force is applied to the PL bundle and a minimal tensioning force to the AM bundle in double bundle reconstruction to obtain better knee kinematics.