Development of on-line lateral stiffness measurement system for anterior cruciate ligament and its influence on anterior cruciate ligament reconstruction_Journal of Biomedical Engineering

Authors：

CUI Ze ¹ ,  CHEN Zenghao ¹ , HUANG Saishuai ¹ , YANG Hongxin ¹ , LEI Jingtao ¹ , ZHU Danjie ²

1. School of Mechatronic Engineering and Automation, Shanghai University, Shanghai 200444, P.R.China;
2. Sports Medicine and Joint Surgery Division, Zhejiang Provincial People’s Hospital, Hangzhou 310014, P.R.China;

Corresponding author：

CHEN Zenghao, Email: zenghaoc@126.com

Keywords：

anterior cruciate ligament reconstruction; biomechanics; force measurement; anterior cruciate ligament measurement system.

DOI：

10.7507/1001-5515.202006060

Video：

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The anterior cruciate ligament (ACL) reconstruction mostly relies on the experience of surgeons. To improve the effectiveness and adaptability of the tension after ACL reconstruction in knee joint rehabilitation, this paper establishes a lateral force measurement model with relaxation characteristics and designs an on-line stiffness measurement system of ACL. In this paper, we selected 20 sheep knee joints as experimental material for the knee joint stability test before the ACL reconstruction operation, which were divided into two groups for a comparative test of single-bundle ACL reconstruction through the anterolateral approach. The first group of surgeons carried out intraoperative detection with routine procedures. The second group used ACL on-line stiffness measurement system for intraoperative detection. After that, the above two groups were tested for postoperative stability. The study results show that the tension accuracy is (− 2.3 ± 0.04)%, and the displacement error is (1.5 ± 1.8)%. The forward stability, internal rotation stability, and external rotation stability of the two groups were better than those before operation (P < 0.05). But the data of the group using the system were closer to the preoperative knee joint measurement index, and there was no significant difference between them (P > 0.05). The system established in this paper is expected to help clinicians judge the ACL reconstruction tension in the operation process and effectively improve the surgical effect.

Citation： CUI Ze, CHEN Zenghao, HUANG Saishuai, YANG Hongxin, LEI Jingtao, ZHU Danjie. Development of on-line lateral stiffness measurement system for anterior cruciate ligament and its influence on anterior cruciate ligament reconstruction. Journal of Biomedical Engineering, 2021, 38(1): 145-153. doi: 10.7507/1001-5515.202006060 Copy

1.	Grunau P D, Arneja S, Leith J M. A randomized clinical trial to assess the clinical effectiveness of a measured objective tensioning device in hamstring anterior cruciate ligament reconstruction. Am J Sports Med, 2016, 44(6): 1482-1486.
2.	Carl I, Craig M, Daniel C, et al. Abnormal tibiofemoral contact stress and its association with altered kinematics following center-center ACL reconstruction: an in vitro study. American Journal of Sports Medicine, 2013, 41(4): 815.
3.	Sakane M, Fox R J, Woo S L, et al. In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res, 1997, 15(2): 285-293.
4.	Branch T, Browne J E, Siebold R, et al. Paper 128: inconsistent manual techniques make qualitative and quantitative analyses of the pivot shift test difficult in both ACL-deficient and intact knees. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2011, 27(10): e152-e153.
5.	Branch T P, Stinton S K, Siebold R, et al. Assessment of knee laxity using a robotic testing device: a comparison to the manual clinical knee examination. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2460-2467.
6.	Rohman E M, Macalena J A. Anterior cruciate ligament assessment using arthrometry and stress imaging. Curr Rev Musculoskelet Med, 2016, 9(2): 130-138.
7.	Hu Yan, Wei Jun, Lei Li, et al. Force-measuring robot for evaluation of anterior cruciate ligament reconstruction. Advanced Materials Research, 2012, 466-467: 1418-1423.
8.	Rachmat H H, Janssen D, Verkerke G J, et al. In-situ mechanical behavior and slackness of the anterior cruciate ligament at multiple knee flexion angles. Med Eng Phys, 2016, 38(3): 209-215.
9.	Kawaguchi S, Nagamune K, Nishizawa Y, et al. Challenge of normality evaluation by using micro-size tension measurement device in anterior cruciate ligament reconstruction//2012 IEEE International Conference on Systems, Man, and Cybernetics (SMC), IEEE, 2012: 2605-2609.
10.	Nishizawa Y, Hoshino Y, Nagamune K, et al. Comparison between intra- and extra-articular tension of the graft during fixation in anterior cruciate ligament reconstruction. Arthroscopy, 2017, 33(6): 1204-1210.
11.	O'Neill B J, Byrne F J, Hirpara K M, et al. Anterior cruciate ligament graft tensioning. Is the maximal sustained one-handed pull technique reproducible?. BMC Res Notes, 2011, 4(1): 244.
12.	Hoshino Y, Kuroda R, Nagamune K, et al. The effect of graft tensioning in anatomic 2-bundle ACL reconstruction on knee joint kinematics. Knee Surg Sports Traumatol Arthrosc, 2007, 15(5): 508-514.
13.	Russell D F, Deakin A H, Fogg Q A, et al. Repeatability and accuracy of a non-invasive method of measuring internal and external rotation of the tibia. Knee Surg Sports Traumatol Arthrosc, 2014, 22(8): 1771-1777.
14.	Mouton C, Theisen D, Pape D, et al. Static rotational knee laxity in anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc, 2012, 20(4): 652-662.
15.	Lamberto G, Amin D, Solomon L B, et al. Personalised 3D knee compliance from clinically viable knee laxity measurements: a proof of concept ex vivo experiment. Med Eng Phys, 2019, 64: 80-85.
16.	Pioletti D P, Rakotomanana L R. Nonlinear viscoelastic laws for soft biological tissues. Eur J Mech A-Solid, 2000, 19(5): 749-759.
17.	Cui Z, Chen Z H, Qian D H, et al. A study of knee anterior cruciate ligament biomechanics with respect to energy and relaxation. Clinical Biomechanics, 2020, 80: 105159.
18.	Duenwald S E, Vanderby R J, Lakes R S. Stress relaxation and recovery in tendon and ligament: experiment and modeling. Biorheology, 2010, 47(1): 1-14.
19.	Gabriel M T, Wong E K, Woo S L, et al. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res, 2004, 22(1): 85-89.
20.	de Jong W H, Carraway J W, Geertsma R E. In vivo and in vitro testing for the biological safety evaluation of biomaterials and medical devices. Biocompatibility and Performance of Medical Devices, 2012: 120-158.
21.	Fleming B C, Beynnon B D. In vivo measurement of ligament/tendon strains and forces: a review. Ann Biomed Eng, 2004, 32(3): 318-328.
22.	Fleming B C, Fadale P D, Hulstyn M J, et al. The effect of initial graft tension after anterior cruciate ligament reconstruction: a randomized clinical trial with 36-month follow-up. Am J Sports Med, 2013, 41(1): 25-34.
23.	Schmitt-Sody M, Kirchhoff C, Luciani E, et al. Dynamic in vitro analysis of tractile forces of the anterior cruciate ligament (ACL) transplant using patellar and semitendinosus muscle tendon: a cadaver study. Arch Orthop Trauma Surg, 2015, 135(1): 29-39.
24.	Chae S, Jung S W, Park H S. In vivo biomechanical measurement and haptic simulation of portal placement procedure in shoulder arthroscopic surgery. PLoS One, 2018, 13(3): e0193736.
25.	Lubowitz J H, Appleby D. Cost-effectiveness analysis of the most common orthopaedic surgery procedures: knee arthroscopy and knee anterior cruciate ligament reconstruction. Arthroscopy, 2011, 27(10): 1317-1322.
26.	Krych A J, Carey J L, Marx R G, et al. Does arthroscopic knee surgery work?. Arthroscopy, 2014, 30(5): 544-545.
27.	Kim S J, Lee S K, Kim S H, et al. Does anterior laxity of the uninjured knee influence clinical outcomes of ACL reconstruction? J Bone Joint Surg Am, 2014, 96(7): 543-548.
28.	Aljehani M, Madara K, Snyder-Mackler L, et al. The contralateral knee may not be a valid control for biomechanical outcomes after unilateral total knee arthroplasty. Gait Posture, 2019, 70: 179-184.
29.	Magnussen R A, Reinke E K, Huston L J, et al. Effect of High-grade preoperative knee laxity on anterior cruciate ligament Reconstruction outcomes. Am J Sports Med, 2016, 44(12): 3077-3082.
30.	van Luijk J, Bakker B, Rovers M M, et al. Systematic reviews of animal studies; missing link in translational research?. PLoS One, 2014, 9(3): e89981.
31.	Deckers C, Stephan P, Wever K E, et al. The protective effect of anterior cruciate ligament Reconstruction on articular cartilage: a systematic review of animal studies. Osteoarthritis Cartilage, 2019, 27(2): 219-229.

1. Grunau P D, Arneja S, Leith J M. A randomized clinical trial to assess the clinical effectiveness of a measured objective tensioning device in hamstring anterior cruciate ligament reconstruction. Am J Sports Med, 2016, 44(6): 1482-1486.
2. Carl I, Craig M, Daniel C, et al. Abnormal tibiofemoral contact stress and its association with altered kinematics following center-center ACL reconstruction: an in vitro study. American Journal of Sports Medicine, 2013, 41(4): 815.
3. Sakane M, Fox R J, Woo S L, et al. In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res, 1997, 15(2): 285-293.
4. Branch T, Browne J E, Siebold R, et al. Paper 128: inconsistent manual techniques make qualitative and quantitative analyses of the pivot shift test difficult in both ACL-deficient and intact knees. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2011, 27(10): e152-e153.
5. Branch T P, Stinton S K, Siebold R, et al. Assessment of knee laxity using a robotic testing device: a comparison to the manual clinical knee examination. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8): 2460-2467.
6. Rohman E M, Macalena J A. Anterior cruciate ligament assessment using arthrometry and stress imaging. Curr Rev Musculoskelet Med, 2016, 9(2): 130-138.
7. Hu Yan, Wei Jun, Lei Li, et al. Force-measuring robot for evaluation of anterior cruciate ligament reconstruction. Advanced Materials Research, 2012, 466-467: 1418-1423.
8. Rachmat H H, Janssen D, Verkerke G J, et al. In-situ mechanical behavior and slackness of the anterior cruciate ligament at multiple knee flexion angles. Med Eng Phys, 2016, 38(3): 209-215.
9. Kawaguchi S, Nagamune K, Nishizawa Y, et al. Challenge of normality evaluation by using micro-size tension measurement device in anterior cruciate ligament reconstruction//2012 IEEE International Conference on Systems, Man, and Cybernetics (SMC), IEEE, 2012: 2605-2609.
10. Nishizawa Y, Hoshino Y, Nagamune K, et al. Comparison between intra- and extra-articular tension of the graft during fixation in anterior cruciate ligament reconstruction. Arthroscopy, 2017, 33(6): 1204-1210.
11. O'Neill B J, Byrne F J, Hirpara K M, et al. Anterior cruciate ligament graft tensioning. Is the maximal sustained one-handed pull technique reproducible?. BMC Res Notes, 2011, 4(1): 244.
12. Hoshino Y, Kuroda R, Nagamune K, et al. The effect of graft tensioning in anatomic 2-bundle ACL reconstruction on knee joint kinematics. Knee Surg Sports Traumatol Arthrosc, 2007, 15(5): 508-514.
13. Russell D F, Deakin A H, Fogg Q A, et al. Repeatability and accuracy of a non-invasive method of measuring internal and external rotation of the tibia. Knee Surg Sports Traumatol Arthrosc, 2014, 22(8): 1771-1777.
14. Mouton C, Theisen D, Pape D, et al. Static rotational knee laxity in anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc, 2012, 20(4): 652-662.
15. Lamberto G, Amin D, Solomon L B, et al. Personalised 3D knee compliance from clinically viable knee laxity measurements: a proof of concept ex vivo experiment. Med Eng Phys, 2019, 64: 80-85.
16. Pioletti D P, Rakotomanana L R. Nonlinear viscoelastic laws for soft biological tissues. Eur J Mech A-Solid, 2000, 19(5): 749-759.
17. Cui Z, Chen Z H, Qian D H, et al. A study of knee anterior cruciate ligament biomechanics with respect to energy and relaxation. Clinical Biomechanics, 2020, 80: 105159.
18. Duenwald S E, Vanderby R J, Lakes R S. Stress relaxation and recovery in tendon and ligament: experiment and modeling. Biorheology, 2010, 47(1): 1-14.
19. Gabriel M T, Wong E K, Woo S L, et al. Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res, 2004, 22(1): 85-89.
20. de Jong W H, Carraway J W, Geertsma R E. In vivo and in vitro testing for the biological safety evaluation of biomaterials and medical devices. Biocompatibility and Performance of Medical Devices, 2012: 120-158.
21. Fleming B C, Beynnon B D. In vivo measurement of ligament/tendon strains and forces: a review. Ann Biomed Eng, 2004, 32(3): 318-328.
22. Fleming B C, Fadale P D, Hulstyn M J, et al. The effect of initial graft tension after anterior cruciate ligament reconstruction: a randomized clinical trial with 36-month follow-up. Am J Sports Med, 2013, 41(1): 25-34.
23. Schmitt-Sody M, Kirchhoff C, Luciani E, et al. Dynamic in vitro analysis of tractile forces of the anterior cruciate ligament (ACL) transplant using patellar and semitendinosus muscle tendon: a cadaver study. Arch Orthop Trauma Surg, 2015, 135(1): 29-39.
24. Chae S, Jung S W, Park H S. In vivo biomechanical measurement and haptic simulation of portal placement procedure in shoulder arthroscopic surgery. PLoS One, 2018, 13(3): e0193736.
25. Lubowitz J H, Appleby D. Cost-effectiveness analysis of the most common orthopaedic surgery procedures: knee arthroscopy and knee anterior cruciate ligament reconstruction. Arthroscopy, 2011, 27(10): 1317-1322.
26. Krych A J, Carey J L, Marx R G, et al. Does arthroscopic knee surgery work?. Arthroscopy, 2014, 30(5): 544-545.
27. Kim S J, Lee S K, Kim S H, et al. Does anterior laxity of the uninjured knee influence clinical outcomes of ACL reconstruction? J Bone Joint Surg Am, 2014, 96(7): 543-548.
28. Aljehani M, Madara K, Snyder-Mackler L, et al. The contralateral knee may not be a valid control for biomechanical outcomes after unilateral total knee arthroplasty. Gait Posture, 2019, 70: 179-184.
29. Magnussen R A, Reinke E K, Huston L J, et al. Effect of High-grade preoperative knee laxity on anterior cruciate ligament Reconstruction outcomes. Am J Sports Med, 2016, 44(12): 3077-3082.
30. van Luijk J, Bakker B, Rovers M M, et al. Systematic reviews of animal studies; missing link in translational research?. PLoS One, 2014, 9(3): e89981.
31. Deckers C, Stephan P, Wever K E, et al. The protective effect of anterior cruciate ligament Reconstruction on articular cartilage: a systematic review of animal studies. Osteoarthritis Cartilage, 2019, 27(2): 219-229.

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