title: Biomechanical evaluation of intra-articular and extra-articular procedures in anterior cruciate ligament reconstruction: a finite element analysis.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Laboratory of Biomechanical Orthopedics EPFL-HOSR, Institute of Translational Biomechanics, Ecole Polytechnique Fédérale de Lausanne, Station 15, 1015 Lausanne, Switzerland.
authors.forename: N A
authors.initials: NA
authors.lastname: Ramaniraka
authors.forename: P
authors.initials: P
authors.lastname: Saunier
authors.forename: O
authors.initials: O
authors.lastname: Siegrist
authors.forename: D P
authors.initials: DP
authors.lastname: Pioletti
mesh_terms: D016118:Anterior Cruciate Ligament / Q000503:physiopathology / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D020342:Finite Element Analysis; D006801:Humans; D007718:Knee Injuries / Q000503:physiopathology / Q000601:surgery*; D007719:Knee Joint / Q000503:physiopathology; D019637:Orthopedic Procedures / Q000379:methods*; D016119:Posterior Cruciate Ligament / Q000503:physiopathology; D012399:Rotation; D016896:Treatment Outcome