Understanding the Interaction Between Graft Placement, Gait Mechanics, and Cartilage Morphology as a Pathway to Osteoarthristis in the ACL Reconstructed Knee

Links

URL: http://purl.stanford.edu/qk493dv5955

Abstract

The overall goal of this dissertation was to address the question of the relationship between anterior cruciate ligament (ACL) graft function, changes in walking mechanics, and the morphology of the articular cartilage in the ACL reconstructed knee as a step towards filling critical gaps in the available knowledge of the association between ACL injury and premature osteoarthritis of the knee. ACL injury often leads to premature osteoarthritis of the knee even when the ACL is reconstructed and alterations in knee mechanics during walking have been identified as a potential mechanism of cartilage degeneration in the ACL deficient knee. This thesis provides the results of experimental studies using magnetic resonance (MR) imaging and gait analysis to understand the effect of ACL reconstruction on the mechanics of walking and articular cartilage morphology in the context of a potential mechanism for the initiation of osteoarthritis. These results provide a basis for improving the treatment and long-term prognosis of the ACL injured knee.

Gait analysis of subjects after ACL reconstruction showed that during the stance phase of walking, their ACL reconstructed knee had significantly more external tibial rotation when compared to their contralateral knee. This kinematic alteration likely causes changes in normal cartilage contact mechanics and could contribute to the eventual degeneration of the articular cartilage. Analysis of ACL graft placement in this population revealed a potential mechanism for the observed alteration in ambulatory mechanics in the ACL reconstructed knee. Variations in graft placement were correlated with the magnitude of the peak external knee flexion moment (balanced by a net quadriceps moment) and the tibiofemoral rotational position of the reconstructed knee during walking. In both cases, non-anatomic graft placement resulted in greater deviations in the ambulatory mechanics of the ACL reconstructed knee.

Since these results indicated graft placement plays a critical role in the restoration of normal ambulatory mechanics, MR imaging was utilized to develop a method to determine the three-dimensional location of native tibial and femoral ACL insertions to guide and evaluate anatomic ACL graft placement. Analysis of healthy and ACL reconstructed subjects revealed the presence of side-to-side symmetry in location of ACL insertions in healthy subjects but not after transtibial ACL reconstruction, indicating that conventional transtibial reconstruction frequently places the graft outside the center of the anatomical ACL footprint. Further examination of the effects of non-anatomic ACL graft placement revealed the unintended consequences of vertical sagittal orientation of the ACL graft. These results demonstrated that although vertical sagittal graft orientation was associated with less occurrence of an active knee extension deficit during walking (as intended), it was also associated with an increased anterior tibial neutral position in the ACL reconstructed knees. Finally, in order to investigate the mechanism of the proposed kinematic pathway to osteoarthritis after ACL reconstruction, the individual-specific femoral cartilage thickness distribution was related to knee flexion during walking in the reconstructed and healthy contralateral knees. The results of this study showed that although a relationship existed in both the reconstructed and contralateral knees, a shift in knee flexion at heel-strike without an adaptation in cartilage thickness distribution caused an alteration in the relationship in the ACL reconstructed knees. Thus failure of the ACL reconstruction to restore normal walking mechanics could contribute the breakdown of articular cartilage in the ACL reconstructed knee.

The results of these studies provide a better understanding of the influence of ACL reconstruction on the subsequent changes in the mechanics of the ACL reconstructed knee. These findings present insights into the complex relationship between variations in ACL graft placement, changes in walking mechanics, and the distribution of cartilage thickness in the context of a potential kinematic mechanism for the development of premature osteoarthritis after ACL injury and reconstruction. Taken together, these results provide a basis for improving the standard of care for the ACL injured knee.

Cited Works (26)

Year	Entry
1998	Andriacchi TP, Alexander EJ, Toney MK, Dyrby C, Sum J. A point cluster method for in vivo motion analysis: applied to a study of knee kinematics. J Biomech Eng. December 1998;120(6):743-749.
2008	Chaudhari AMW, Briant PL, Bevill SL, Koo S, Andriacchi TP. Knee kinematics, cartilage morphology, and osteoarthritis after ACL injury. Med Sci Sports Exer. February 2008;40(2):215-222.
2005	Andriacchi TP, Dyrby CO. Interactions between kinematics and loading during walking for the normal and ACL deficient knee. J Biomech. February 2005;38(2):293-298.
1991	Schipplein OD, Andriacchi TP. Interaction between active and passive knee stabilizers during level walking. J Orthop Res. January 1991;9(1):113-119.
1991	Clark JM. Variation of collagen fiber alignment in a joint surface: a scanning electron microscope study of the tibial plateau in dog, rabbit, and man. J Orthop Res. March 1991;9(2):246-257.
1999	Li G, Rudy TW, Sakane M, Kanamori A, Ma CB, Woo SL-Y. The importance of quadriceps and hamstring muscle loading on knee kinematics and in-situ forces in the ACL. J Biomech. April 1999;32(4):395-400.
1980	Butler DL, Noyes FR, Grood ES. Ligamentous restraints to anterior-posterior drawer in the human knee: a biomechanical study. J Bone Joint Surg. March 1980;62A(2):259-270.
2002	Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Ann Rheum Dis. July 2002;61(6):617-622.
2006	Andriacchi TP, Briant PL, Bevill SL, Koo S. Rotational changes at the knee after ACL injury cause cartilage thinning. Clin Orthop Relat Res. January 2006;442:39-44.
1994	Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med. September–October 1994;22(5):632-644.
2004	Andriacchi TP, Mündermann A, Smith RL, Alexander EJ, Dyrby CO, Koo S. A framework for the in vivo pathomechanics of osteoarthritis at the knee. Ann Biomed Eng. March 2004;32(3):447-457.
2005	Andriacchi TP, Johnson TS, Hurwitz DE, Natarajan RN. Musculoskeletal dynamics, locomotion, and clinical applications. In: Mow VC, Huiskes R, eds. Basic Orthopaedic Biomechanics & Mechano-Biology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:91-122.
2006	Andriacchi TP, Mündermann A. The role of ambulatory mechanics in the initiation and progression of knee osteoarthritis. Curr Opin Rhuematol. September 2006;18(5):514-518.
1975	Girgis FG, Marshall JL, Al Monajem ARS. The cruciate ligaments of the knee joint: anatomical, functional and experimental analysis. Clin Orthop Relat Res. January–February 1975;106:216-231.
1982	Mankin HJ. The response of articular cartilage to mechanical injury. J Bone Joint Surg. March 1982;64A(3):460-466.
1995	Roos H, Adalberth T, Dahlberg L, Lohmander LS. Osteoarthritis of the knee after injury to the anterior cruciate ligament or meniscus: the influence of time and age. Osteoarthritis Cartilage. December 1995;3(3):261-267.
2007	Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. October 2007;35(10):1756-1769.
1991	Brandt KD, Myers SL, Burr D, Albrecht M. Osteoarthritic changes in canine articular cartilage, subchondral bone, and synovium fifty-four months after transection of the anterior cruciate ligament. Arthritis Rheum. December 1991;34(12):1560-1570.
2000	Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics. June 2000;23(6):573-578.
1999	Arendt EA, Agel J, Dick R. Anterior cruciate ligament injury patterns among collegiate men and women. J Athl Train. June 1999;34(2):86-92.
2004	Lohmander LS, Östenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. October 2004;50(10):3145-3152.
1992	Lafortune MA, Cavanagh PR, Sommer HJ III, Kalenak A. Three-dimensional kinematics of the human knee during walking. J Biomech. April 1992;25(4):347-357.
2006	Bey MJ, Zauel R, Brock SK, Tashman S. Validation of a new model-based tracking technique for measuring three-dimensional, in vivo glenohumeral joint kinematics. J Biomech Eng. August 2006;128(4):604-609.
2005	Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. April 2005;33(4):492-501.
2010	Liu F, Kozanek M, Hosseini A, Van de Velde SK, Gill TJ, Rubash HE, Li G. In vivo tibiofemoral cartilage deformation during the stance phase of gait. J Biomech. March 3, 2010;43(4):658-665.
2004	von Porat A, Roos EM, Roos H. High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes. Ann Rheum Dis. March 2004;63(3):269-273.