Anterior cruciate ligament graft fixation first in anterior and posterior cruciate ligament reconstruction best restores knee kinematics

Knee Surg Sports Traumatol Arthrosc. 2018 Apr;26(4):1237-1244. doi: 10.1007/s00167-017-4615-6. Epub 2017 Jun 23.


Purpose: To evaluate the effect of different graft fixation sequences in one-stage anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction on (1) knee biomechanics and (2) tibiofemoral alignment.

Methods: Twelve porcine knees were used in this study. Five fixation sequences were performed (angle indicating knee flexion): (a) PCL at 30° and ACL at 30°, (b) PCL at 90° and ACL at 30°, (c) ACL at 30° and PCL at 30°, (d) ACL at 30° and PCL at 90°, and (e) ACL and PCL simultaneous fixation at 30°. Anterior and posterior tibial translation was measured under an 89 N load. A 3-D digitizer was used to measure the change in anteroposterior (AP) tibiofemoral position.

Results: None of the graft fixation sequences restored the AP laxity of the intact knee, and there are minimal differences in the in situ tissue forces in the ACL and PCL grafts. The reconstructions with fixation of the PCL graft first resulted in a significantly larger change in AP tibiofemoral position from the intact knee at 60° and 90° of knee flexion than the reconstructions with fixation of the ACL graft first (p < 0.05).

Conclusion: Fixation of the ACL graft at 30° of knee flexion followed by fixation of the PCL graft can best restore the tibiofemoral position of the intact knee. This study has clinical relevance in regard to the effect of graft fixation sequence on the position of the tibia relative to the femur in one-stage ACL and PCL reconstruction.

Keywords: Multiligamentous injuries; One-stage ACL and PCL reconstruction; Porcine.

MeSH terms

  • Animals
  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Reconstruction / adverse effects
  • Anterior Cruciate Ligament Reconstruction / methods*
  • Biomechanical Phenomena
  • Bone Malalignment / etiology
  • Bone Malalignment / prevention & control*
  • Disease Models, Animal
  • Knee Injuries / physiopathology
  • Knee Injuries / surgery*
  • Knee Joint / physiopathology*
  • Knee Joint / surgery
  • Posterior Cruciate Ligament / surgery*
  • Posterior Cruciate Ligament Reconstruction / adverse effects
  • Posterior Cruciate Ligament Reconstruction / methods*
  • Reconstructive Surgical Procedures / adverse effects
  • Reconstructive Surgical Procedures / methods
  • Swine
  • Tendons / transplantation