Biomechanical evaluation of intra-articular and extra-articular procedures in anterior cruciate ligament reconstruction: a finite element analysis

BACKGROUND: Intra-articular techniques (single and double bundles) are the most widely used procedures for the anterior cruciate ligament reconstruction. Lemaire introduced in 1967 the extra-articular techniques, and combined intra-articular and extra-articular reconstruction, to better restore the stability of the knee. However, the effectiveness of these procedures (intra-articular, extra-articular combined or not with intra-articular) seems to be controversial. METHODS: In the present study, we developed numerical models of a knee joint to evaluate the effects of these different procedures on the kinematics and biomechanics of the knee during an internal rotation test. Six cases were simulated: intact anterior cruciate ligament, intra-articular reconstructed anterior cruciate ligament (single and double bundles), extra-articular reconstructed anterior cruciate ligament alone, and combination of extra- and intra-articular reconstructions. The loading condition was an internal tibial torque of 2 N m at 0 degrees, 15 degrees, 30 degrees and 45 degrees of knee flexion. Internal rotation of the tibia and forces within the grafts and the ligaments were calculated. FINDINGS: This study showed that both single and double bundles intra-articular reconstructions restore similar internal rotation control and biomechanics of the soft structures as the intact anterior cruciate ligament situation. On the other hand, our results indicate that extra-articular reconstruction reduces appreciably the internal rotation and modifies the charges distribution in the soft structures when compared to the intact anterior cruciate ligament. INTERPRETATION: The extra-articular procedure alters the kinematics of the knee, which might overconstraint the ligaments and the femorotibial joints, leading to the failure of the anterior cruciate ligament reconstruction.