Andrew A. Amis

Anatomy and biomechanics of the medial patellofemoral ligament

The medial patellofemoral ligament (MPFL) is a band of retinacular tissue connecting the femoral medial epicondyle to the medial edge of the patella. The MPFL is approximately 55 mm long, and its width has been reported to range from 3 to 30 mm. The MPFL is overlaid by the distal part of vastus medialis obliquus to a variable extent, and fibres of MPFL merge into the deep aspect of the muscle. Despite the MPFL being very thin, it had a mean tensile strength of 208 N, and has been reported to be the primary passive restraint to patellar lateral displacement. Lateral patellar displacement tests in vitro showed that the patella subluxed most easily at 20 degrees knee flexion. The contribution of the MPFL to resisting patellar lateral subluxation was greatest in the extended knee. This finding was linked to the retinaculae being tightest in full knee extension, and slackening with flexion.

The effects of articular, retinacular, or muscular deficiencies on patellofemoral joint stability: A BIOMECHANICAL STUDY IN VITRO

Normal function of the patellofemoral joint is maintained by a complex interaction between soft tissues and articular surfaces. No quantitative data have been found on the relative contributions of these structures to patellar stability. Eight knees were studied using a materials testing machine to displace the patella 10 mm laterally and medially and measure the force required. Patellar stability was tested from 0 degrees to 90 degrees knee flexion with the quadriceps tensed to 175 N. Four conditions were examined: intact, vastus medialis obliquus relaxed, flat lateral condyle, and ruptured medial retinaculae. Abnormal trochlear geometry reduced the lateral stability by 70% at 30 degrees flexion, while relaxation of vastus medialis obliquus caused a 30% reduction. Ruptured medial retinaculae had the largest effect at 0 degrees flexion with 49% reduction. There was no effect on medial stability. There is a complex interaction between these structures, with their contributions to loss of lateral patellar stability varying with knee flexion.

A Biomechanical Comparison of Single and Double-Row Fixation in Arthroscopic Rotator Cuff Repair

BACKGROUND The optimal method for arthroscopic rotator cuff repair is not yet known. The hypothesis of the present study was that a double-row repair would demonstrate superior static and cyclic mechanical behavior when compared with a single-row repair. The specific aims were to measure gap formation at the bone-tendon interface under static creep loading and the ultimate strength and mode of failure of both methods of repair under cyclic loading. METHODS A standardized tear of the supraspinatus tendon was created in sixteen fresh cadaveric shoulders. Arthroscopic rotator cuff repairs were performed with use of either a double-row technique (eight specimens) or a single-row technique (eight specimens) with nonabsorbable sutures that were double-loaded on a titanium suture anchor. The repairs were loaded statically for one hour, and the gap formation was measured. Cyclic loading to failure was then performed. RESULTS Gap formation during static loading was significantly greater in the single-row group than in the double-row group (mean and standard deviation, 5.0 +/- 1.2 mm compared with 3.8 +/- 1.4 mm; p < 0.05). Under cyclic loading, the double-row repairs failed at a mean of 320 +/- 96.9 N whereas the single-row repairs failed at a mean of 224 +/- 147.9 N (p = 0.058). Three single-row repairs and three double-row repairs failed as a result of suture cut-through. Four single-row repairs and one double-row repair failed as a result of anchor or suture failure. The remaining five repairs did not fail, and a midsubstance tear of the tendon occurred. CONCLUSIONS Although more technically demanding, the double-row technique demonstrates superior resistance to gap formation under static loading as compared with the single-row technique. CLINICAL RELEVANCE A double-row reconstruction of the supraspinatus tendon insertion may provide a more reliable construct than a single-row repair and could be used as an alternative to open reconstruction for the treatment of isolated tears.

Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction

The tensile strength of the medial patellofemoral ligament (MPFL), and of surgical procedures which reconstitute it, are unknown. Ten fresh cadaver knees were prepared by isolating the patella, leaving only the MPFL as its attachment to the medial femoral condyle. The MPFL was either repaired by using a Kessler suture or reconstructed using either bone anchors or one of two tendon grafting techniques. The tensile strength and the displacement to peak force of the MPFL were then measured using an Instron materials-testing machine. The MPFL was found to have a mean tensile strength of 208 N (SD 90) at 26 mm (SD 7) of displacement. The strengths of the other techniques were: sutures alone, 37 N (SD 27); bone anchors plus sutures, 142 N (SD 39); blind-tunnel tendon graft, 126 N (SD 21); and through-tunnel tendon graft, 195 N (SD 66). The last was not significantly weaker than the MPFL itself.

The Role of the Medial Collateral Ligament and Posteromedial Capsule in Controlling Knee Laxity

Background The medial aspect of the knee has a complex capsular structure; the biomechanical roles of specific structures are not well understood. Hypothesis The 3 strong stabilizing structures, the superficial and deep medial collateral ligaments and the posteromedial capsule, make distinct contributions to controlling tibiofemoral laxity. Study Design Controlled laboratory study. Methods Changes in knee laxity under anterior-posterior drawer, valgus, and internal-external rotation loads were found by sequential cutting in 18 cadaveric knees. Three cutting sequences allowed the roles of the 3 structures to be seen in isolation and in combination. Some force contributions were also calculated. Results The posteromedial capsule controlled valgus, internal rotation, and posterior drawer in extension, resisting 42% of a 150-N drawer force when the tibia was in internal rotation. The superficial collateral ligament controlled valgus at all angles and was dominant from 30° to 90° of flexion, plus internal rotation in flexion. The deep collateral ligament controlled tibial anterior drawer of the flexed and externally rotated knee and was a secondary restraint to valgus. Conclusion Distinct roles in controlling tibiofemoral laxity have been found for these structures that vary according to knee flexion and tibial rotation. Clinical Relevance The restraining functions demonstrated provide new information about knee stabilization, which may allow better evaluation of structural damage at the medial aspect of the knee.

An anatomical study of meniscal allograft sizing

Meniscus-to-femoral condyle congruity is essential for the development of circumferential hoop stresses and thus function of the meniscus. When meniscal allograft transplantation is performed using bony anchorage of the insertional ligaments, accurate graft-to-host size matching is therefore essential. The standard method currently employed for size matching of meniscal allografts is to rely on plain radiographs of the hosts knee, from which expected meniscal dimensions are measured. This study aimed to examine the correlation between tibial plateau dimensions and meniscal dimensions. We studied 44 donor tibial plateaus with medial and lateral meniscal allografts attached intact. Meniscal and tibial plateau dimensions were measured. Linear regression analysis was used to calculate expected meniscal dimensions from each specimens plateau dimensions. Using specific medial and lateral tibial plateau width and length measurements, meniscal dimensions could be predicted with a mean error of only 5.0±6.4%. When predicting meniscal dimensions from only total bony plateau width, the mean error observed was 6.2±8.0%. The difference between the two methods was not statistically significant. The results suggest that meniscal dimensions can be predicted accurately from tibial plateau measurements, with only small mean errors. However, potential size mismatches should be carefully borne in mind by surgeons using meniscal allografts.

Fixation of the graft in reconstruction of the anterior cruciate ligament

Methods of reconstruction of the anterior cruciate ligament (ACL) have developed considerably over the last 15 years. Primary repair and extra-articular procedures have failed to reproduce satisfactory stability of the knee[1][1] and the use of prosthetic ligaments has been abandoned.[2][2] These

Strength of the suture in the epitenon and within the tendon fibres: Development of stronger peripheral suture technique

In tendon repair, the peripheral stitches are usually placed in the epitenon, but it has not yet been defined whether the grasping strength of the sutures in the epitenon and within the tendon fibres are different. The first stage of this work investigated this difference and found that peripheral stitches within cadaveric tendon fibres were 83% stronger than those in the epitenon layer. A new peripheral stitch, based on this finding, has been designed. Mechanical tests of a range of peripheral suture types in vitro found that the new technique gave a resistance to gap formation twice that of the peripheral stitches commonly in use at present and a rupture strength more than three times, while still avoiding eversion problems.

The Remains of Anterior Cruciate Ligament Graft Tension After Cyclic Knee Motion

Background There is sometimes a return of excess knee laxity after anterior cruciate ligament reconstruction. One of the contributing factors might be a loss in graft tension. It is unknown whether the tension imposed on an anterior cruciate ligament graft degrades with time and, if so, the effect of that loss of tension on knee laxity. Hypotheses The pretension in the anterior cruciate ligament graft reduces significantly within the first 500 motion cycles, and this decrease in graft tension causes an increase in knee laxity. Study Design Controlled laboratory study. Methods This study measured the remains of bone-patellar tendon-bone graft pretension after cyclical flexion-extension and the effect of any tension loss on knee laxity, using 8 cadaveric knees. A tension transducer was inserted into the graft and calibrated in situ. The reconstruction tension was 40 N at 20° of flexion. In test 1, the graft tension was measured under cyclical flexion-extension in a motorized rig up to 1500 cycles. Test 2, with a new graft, also included anteroposterior and internal-external rotational knee laxity measurements at 0, 500, and 1500 cycles. Results The graft tension at 0° of flexion dropped from 208 N, by 25% after 50 cycles, 41% by 500, and 46% by 1500 cycles. Anterior laxity increased from +1.4 to +2.8 mm by 500 cycles, and performing these laxity tests also caused significant tension losses. Clinical Relevance These results provide one possible explanation for early slackening of anterior cruciate ligament reconstructions.

The Effect of Locking Loops on the Strength of Tendon Repair

A multiple X-raying method has been developed which allows examination of how the particular features of suturing techniques collapse or pull out of the tendon during tensile testing. This technique was used to examine the locking loop tendon sutures, such as the modified Kessler, Verdan and Ketchum techniques. Locking loops did not contribute towards the strength when small diameter sutures (5/0) of various materials were applied to the tendon, collapsing at 12 Newtons. Larger diameter sutures (4/0) slightly reduced the risk of failure of locking loops, but they still collapsed at 15 Newtons or less, so suture techniques which depend on locking loops will often lead to gap formation at low loads and hence poor results.