Biomechanical comparison of rotational activities between anterior cruciate ligament- and posterior cruciate ligament-reconstructed patients

KNEE

Biomechanical comparison of rotational activitiesbetween anterior cruciate ligament- and posteriorcruciate ligament-reconstructed patients

Bee Oh Lim • Han Sol Shin • Yong Seuk Lee

Received: 31 January 2013 / Accepted: 3 March 2014

� Springer-Verlag Berlin Heidelberg 2014

Abstract

Purpose The purpose of this study was to compare the

early functional recovery using biomechanical properties

between anterior cruciate ligament (ACL)- and posterior

cruciate ligament (PCL)-reconstructed patients and to

determine the biomechanical deficit of PCL-reconstructed

patients compared to ACL-reconstructed patients.

Methods A motion analysis system was used to measure

and calculate kinematic and kinetic data for 10 patients

who underwent PCL-reconstructed patients [experimental

group (group 1)], 10 ACL-reconstructed patients (group 2),

and 10 healthy subjects (group 3) during 45�, 90�, 135�,

and 180� cutting and turn running tasks. Groups 1 and 2

were assessed at 3 (return to daily activity) and 6 months

(return to light sports) postoperatively.

Results At 3 months postoperatively, compared to groups

2 and 3, group 1 showed a decrease in knee flexion angle,

extension moment, valgus moment, external rotational

moment, ground reaction force, and increased hamstring–

quadriceps ratio. At 6 months postoperatively, results from

group 1 resembled those of groups 2 and 3 over time.

Conclusions Patients who underwent PCL reconstruction

showed some biomechanical deficits in performance of

activities requiring rotation, compared to those who

underwent ACL reconstruction. Therefore, the

modification of a rehabilitation programme for patients

who underwent PCL reconstruction would be necessary for

improvement of the biomechanical properties during per-

formance of dynamic activities.

Level of evidence Case–control study, Level III.

Keywords Knee � Ligament � Rehabilitation � Motion

analysis � Kinetics � Kinematics

Introduction

Functional adaptation after ligament injury and knee sur-

gery begins with protective weight bearing and progresses

to restoration of normal walking on a variety of surfaces,

ultimately leading to a return to work and sports activities.

The general guidelines for rehabilitation of knees with

ligament injury are based on the promotion of tissue

healing, decreasing pain, and swelling, restoring full

motion, increasing muscular strength and endurance,

improving proprioception, enhancing dynamic stability of

the knee, and reducing functional limitations and disability

[11]. The progress of the patient through this sequence

must be individualized and depends on the pattern of lig-

ament injury or surgical procedure [11].

Exercises for both the quadriceps and hamstring are

emphasized, and accelerated rehabilitation programmes are

being introduced after anterior cruciate ligament (ACL)

reconstruction [11]. In contrast to the ACL rehabilitation,

accelerated posterior cruciate ligament (PCL) postopera-

tive rehabilitation is generally undesirable and most sur-

geons and physical therapist are using more conservative

method than that of ACL reconstruction [4, 5]. However,

the rehabilitation protocol of a PCL reconstruction is not

well established and the articles that do describe the

B. O. Lim

Physical Educational LAB of Chungang University and

Department of Physical Education, Chungang University,

Seoul, South Korea

H. S. Shin � Y. S. Lee (&)

Department of Orthopaedic Surgery, Seoul National University

College of Medicine, Bundang Hospital, 166 Gumi-ro,

Bundang-gu, Songnam-si, Gyeonggi-do 463-707, South Korea

e-mail: [email protected]; [email protected]

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-014-2959-8

postoperative rehabilitation rarely provide the reasoning

behind their protocols [4, 12].

After PCL reconstruction, active flexion exercises should

be avoided because contraction of the hamstrings results in

posterior translation of the tibia and active contraction of

the hamstrings impose undue stress on the healing tissues

[11]. Therefore, Fanelli et al. [5] stated that accelerated PCL

postoperative rehabilitation is undesirable, and a slow and

deliberate postoperative rehabilitation programme is vital to

achievement of a successful outcome after PCL surgery. In

contrast to the PCL, accelerated rehabilitation programmes

have been introduced after ACL reconstruction and these

have resulted in some improvements in clinical results and

patient satisfaction [27, 28].

In terms of functional recovery after PCL reconstruction,

PCL-reconstructed patients have been reported to show

reluctance to engage in daily activities requiring rotation

(cutting and turning) during the early postoperative period

and showed persistent muscle weakness at 2 years after sur-

gery [7, 18, 20]. In addition, because most studies conducted

an evaluation with straight line running, which may not pro-

duce sufficient rotational torque to initiate rotational insta-

bility, there is some possibility that the functional disability

would be accentuated with a high level of activity [35].

Therefore, the purpose of this study was to compare the

early functional recovery using biomechanical properties

between ACL- and PCL-reconstructed patients and to

determine the biomechanical deficit of PCL-reconstructed

patients compared to ACL-reconstructed patients. Our

hypothesis was that PCL-reconstructed patients would

show decreased knee flexion and external rotational

moment because these activities are prohibited during the

early period of rehabilitation.

Materials and methods

Data collection

Transtibial double-bundle ACL reconstruction was per-

formed and four-strand hamstring autograft was used for

the AM bundle and a splitted two-stranded Achilles allo-

graft was used for the posterolateral (PL) bundle [19].

Transtibial single-bundle PCL reconstruction was per-

formed using a tibialis allograft [1, 13]. This study enrolled

30 subjects. Group 1 included 10 patients who underwent

PCL reconstruction (experimental group), group 2 included

10 patients who underwent ACL reconstruction, and group

3 included 10 healthy subjects who had no history of lower

extremity injuries.

Power analysis was performed [22]. For an effect size of

0.5 based on pilot knee flexion peak torque (0.2-Nm/BW

difference), knee flexion average power (0.2-Watts/BW

difference), knee flexion flexibility (4.0� difference),

maximum knee flexion angle (1.6� difference), knee dis-

tance (2.1-cm difference), HQ ratios (11.0 % difference),

maximum knee extension torque (28.0-Nm difference), and

maximum knee external valgus moment (12.0-Nm differ-

ence), the PASS 2002 program was used for power analysis

by NCSS (Kaysville, Utah).

Three trials of cutting 45�, 90�, 135�, 180� turn walking,

and 180� turn running tasks were performed; a successful

trial was defined as the subject performing the task as

instructed with successful collection of videographic and

analogue data [20, 21]. Measurement of functional per-

formance was taken at 3 (return to daily activity and

minimum requirement for performing these tasks) and

6 months (return to light sports) postoperatively. Rehabil-

itation programmes of groups 1 and 2 followed the routine

protocols of our hospital (Table 1). It is only based on the

experience of our series and clinical results. Our institu-

tional review board approved the use of human subjects in

this study, and written consent was obtained from each of

the study participants.

Three-dimensional motion, ground reaction force, and

electromyography analyses of the running task were per-

formed. Selected kinematic and kinetic variables, including

knee flexion angle, knee extension moment, knee valgus

moment, knee external rotation moment, peak ground

reaction force, and hamstring–quadriceps (HQ) ratio, were

analysed [20, 21]. On arrival at the laboratory, participants

observed a demonstration of the tasks and were asked to

warm up for a minimum of 5 min prior to testing and were

then encouraged to continue moving between trials. Par-

ticipants were required to perform a cutting 45�, 90�, 135�,

and 180� turn walking, and 180� turn running task along

the laboratory gateway.

White tape was placed at 45�, 90�, and 135� angles from

the force plate in order to provide visual feedback. Subjects

were instructed to walk and run at their normal comfortable

(natural) approach speed. The trials within the range of the

approach speed 2.9 (SD 0.2) m/s in walk and 3.5 (SD 0.3)

m/s in run were analysed [10, 16]. Because speed changes

have the potential to affect the results, statistical analysis of

the speeds between groups and across times was conducted

in order to identify any potential differences.

Six video cameras (Motion Master 100; Visol Corp.,

Gwangmyeong, Korea), one force plate (AMTI ORG-6;

Advanced Medical Technology Inc., Watertown, MA,

USA), and an 8-channel surface EMG system (Noraxon,

Scottsdale, AZ, USA) were used for data collection. Each

camera was calibrated using a calibration frame (2 m

long 9 2 m wide 9 2 m high) prior to data collection. In

addition, two pairs of electrodes (1 cm in diameter and 3 cm

centre-to-centre distance) were placed on the quadriceps

(rectus femoris) and hamstring (biceps femoris) muscles in


123

order to monitor activity. Prior to attachment of electrodes,

the skin was shaved and cleaned using an alcohol swab. Data

on the force plate were collected at 1,200 Hz, and video data

were captured at 200 fields/s. Kwon 3D XP (Visol),

KwonGRF 2.0 (Visol), and MyoResearch 1.04 (Noraxon)

were used for collection of motion, ground reaction, and

EMG data, respectively [20–22].

During data collection sessions, participants were asked

to wear spandex trunks and pants and to perform the tasks

while barefoot. Spherical reflective markers were placed on

the lower extremities and the pelvis, at the second toes,

heels, lateral malleoli, medial malleoli, lateral shanks, lat-

eral epicondyles, medial epicondyles, lateral thighs, greater

trochanters, anterior superior iliac spines (ASIS), and

sacrum. Markers were placed on the lateral aspects of the

mid shank and thigh on the line connecting the proximal

and distal joints of the segment and projected to the sagittal

plane. A static trial with the participant standing upright

with arms folded on the chest and feet 20 cm apart was

performed in order to establish the positions of joint centres

(hip, knee, and ankle) with respect to surface markers and

the orientations of segmental reference frames to the global

(laboratory) reference frame. Medial epicondyle and mal-

leolus markers and greater trochanter markers were

removed for the dynamic trials [20–22].

Data processing

Three-dimensional (3D) marker coordinates were com-

puted from 2D image coordinates of markers and camera

parameters. Marker coordinates were subject to digital

filtering using a fourth-order zero phase-lag Butterworth

low-pass filter with a cut-off frequency of 12 Hz, before

computing positional data. The centre position of the hip

joint was computed based on the ASIS (right and left),

sacrum, and greater trochanter markers, as detailed in the

Tylkowsky–Andriacchi hybrid method [2]. The mid-point

of the malleolus markers was used as the ankle joint centre,

and the epicondyle markers were used as the knee joint

centre. The pelvis reference frame was defined from the

right ASIS, left ASIS, and sacrum markers. Thigh and

shank reference frames were defined from the hip, knee,

and ankle joint centres, and the lateral thigh and shank

markers. Vectors drawn from the distal to proximal joints

were used as longitudinal axes, and the plane formed by

proximal and distal joints and the corresponding lateral

marker was used as the frontal plane. The knee flexion

angle was obtained from the orientation of the shank ref-

erence frame to the thigh reference frame. The Euler angles

of the shank to the thigh were computed based on the

rotation sequence of flexion/extension, adduction/abduc-

tion, and internal/external rotation. Data on 3D motion and

ground reaction force were combined for computation of

knee flexion/extension, adduction/abduction, and internal/

external moment using inverse dynamics procedures [20,

21].

Raw EMG data were full-wave-rectified and low-pass-

filtered (Butterworth low-pass filter; cut-off fre-

quency = 10 Hz) in order to produce a linear envelope

before integration of signals. The HQ ratio (%) was defined

Table 1 Main stream of our

rehabilitation programme

ROM range of motion

Postoperation ACL PCL

Until 6 weeks Control of inflammation Immobilization in full extension with

posterior pad

0�–90� ROM exercise until 2 weeks Partial weight bearing with 0� locked brace

Full weight bearing with brace Prone passive flexion exercise

Active quadriceps and hamstring exercise Supine passive ROM with both hands

support

120� ROM increase until 6 weeks Calf raise and quadriceps exercise

Normal gait pattern 90� ROM increase until 6 weeks

After 6 weeks More than 120� ROM exercise 90�–120� ROM exercise

Brace off Full weight bearing with brace

Closed kinetic chain exercise Normal gait pattern

After 12 weeks Open kinetic chain exercise More than 120� ROM exercise

Shuttle running Hamstring strengthening exercise

Carioca Closed kinetic chain exercise

Jumping rope Brace off

Light running Straight line running

After 6 months Competitive sports Light sports

Return to previous activities Competitive sports after 9 months


123

as follows: rectus femoris IEMG (integrated EMG)

average/(biceps femoris IEMG average ? rectus femoris

IEMG average) 9 100. The ground reaction and

moment data were normalized to body mass. The EMG

data were normalized to maximal EMG amplitudes

obtained during the stance phase in order to compensate

for maximal voluntary contractions (MVC) of the rectus

femoris and biceps femoris. Events were defined based

on the timing of the ground contact foot on the force

plate at foot contact and at toe off. The dependent

variables were analysed from the stance phase on the

force plate [21].

Statistics

Statistical analyses were conducted in SPSS for Win-

dows, version 16.0 (SPSS inc., Chicago, 162 Illinois).

The dependent variables were maximum knee flexion

angle, knee extension moment, knee valgus moment,

knee external rotation moment, peak ground reaction

force, and mean HQ ratio. In this controlled laboratory

study, three-way repeated-measures ANOVA were ana-

lysed with group, task, and period as between and

within factors. Post hoc tests with a Scheffe correction

were performed when significant factor effects and/or

interactions were observed. The control group per-

formed only once not twice in the every 5 tasks and set

the baseline. We treat the baseline date once when

undertaking the ANOVA. p values \0.05 were consid-

ered statistically significant.

Results

We found that a minimum of 10 subjects per group were

needed for a power of 84 % for p = 0.05. The mean age

of group 1 was 34.5 (SD 7.2) years, the mean height

was 174.2 (SD 6.3) cm, and the mean body mass was

74.2 (SD 8.1) kg. The mean age of group 2 was 31.6

(SD 7.0) years, the mean height was 175.9 (SD 7.2) cm,

and the mean body mass was 73.0 (SD 7.3) kg. The

mean age of group 3 was 33.4 (SD 6.0) years, the mean

height was 175.9 (SD 8.6) cm, and the mean body mass

was 76.0 (SD 7.3) kg. No statistical significances in

speeds were observed between groups and across times

(p = 0.1–0.75). Detailed knee kinematics and kinetics

variables during performance of tasks are shown in

Figs. 1, 2, 3, 4, and 5.

Knee flexion angle

Figure 1 demonstrates that group 1 had lower knee flexion

values than the other groups during the tasks (p = 0.09 and

0.000). Group 2 values were closer to the healthy control

(group 3) than group 1. At 6 months postoperatively,

groups 1 and 2 were similar to the healthy controls, with

greater knee flexion angles during the tasks than at

3 months postoperatively (p = 0.004) (Figs. 2, 3, 4, 5, 6).

Knee extension moment

Figure 2 demonstrates that group 1 showed lower knee

extension moments than group 3 during the tasks

(p = 0.013). However, no statistical differences existed

between groups 1 and 2 (p = 0.403), or groups 2 and 3

(p = 0.176). At 6 months postoperatively, groups 1 and 2

were similar to the healthy controls, with greater knee

extension moments during the tasks than at 3 months post-

operatively (p = 0.017) (Figs. 2, 3, 4, 5, 6).

Fig. 1 Comparison of knee flexion angle according to group, task,

and period

Fig. 2 Comparison of knee extension moment according to group,

task, and period


123

Knee valgus moment

Figure 3 demonstrates that group 1 showed lower knee

valgus moments than group 3 during the tasks (p = 0.003).

However, no statistical differences existed between groups

1 and 2 (p = 0.168), or groups 2 and 3 (p = 0.164). At

6 months postoperatively, groups 1 and 2 were similar to

the healthy controls, with higher knee external moments

during the tasks, compared to 3 months postoperatively

(p = 0.017) (Figs. 2, 3, 4, 5, 6).

Knee external rotation moment

Figure 4 demonstrates that the group 1 had lower knee

external rotation moments than controls during the tasks

(p = 0.004). No statistical differences were observed when

comparing groups 1 and 2 (p = 0.450), or groups 2 and 3


resembled the healthy controls, with increased knee

external rotation moments during the tasks, compared to

results from 3 months postoperatively (p = 0.011)

(Figs. 2, 3, 4, 5, 6).

Ground reaction force

Figure 5 demonstrates that the groups 1 and 2 had lower

ground reaction force than group 3 during the tasks

(p = 0.001 and 0.046, respectively). However, no statisti-

cal differences were observed between groups 1 and 2


were similar to healthy controls and had greater ground

Fig. 3 Comparison of knee valgus moment according to group, task,

and period

Fig. 4 Comparison of knee external rotation moment according to

group, task, and period

Fig. 5 Comparison of ground reaction force according to group, task,

and period

Fig. 6 Comparison of HQ ratio according to group, task, and period


123

reaction force during the tasks than at 3 months postoper-

atively (p = 0.011) (Figs. 2, 3, 4, 5, 6).

Hamstring–quadriceps ratio

Figure 6 demonstrates that the group 1 had higher HQ

ratios than group 3 during the tasks (p = 0.003). However,

by comparing groups 1 and 2 (p = 0.323), or groups 2 and

3 (p = 0.094), there were no significant differences. At

6 months postoperatively, groups 1 and 2 resembled the

healthy controls, with HQ ratios decreased during the tasks

relative to 3 months postoperatively (p = 0.000) (Figs. 2,

3, 4, 5, 6).

Discussion

The principal finding of this study was that patients who

underwent PCL reconstruction had decreased knee flexion

angles, extension moments, valgus moments, external

rotation moments, ground reaction forces, and increased

HQ ratios compared to patients who underwent ACL

reconstruction and healthy control subjects. With time, all

parameters resembled those of healthy controls. However,

compared to the PCL-reconstructed patients, ACL-recon-

structed patients had results similar to those of healthy

subjects at 3 months postoperatively. While the results of

knee functional testing remain inconclusive in regard to

residual strength deficit, tibial rotation is critical for correct

knee joint biomechanics [24].

In the majority of studies reporting ACL reconstruction

using the hamstring or patellar tendon autograft, tibial

rotation was not restored to previous physiological levels

during performance of an activity with increased rotational

loading at the knee [31, 33]. In particular, flexion and

internal rotational strength deficits following hamstring

ACL reconstruction have been frequently reported [25, 34].

However, some studies have reported that external rota-

tional strength deficit was more prominent in patellar ten-

don than hamstring ACL reconstruction [33, 34]. They

hypothesized that the increase in external rotation strength

following hamstring graft harvest is due primarily to

hypertrophy of the biceps femoris, which, while simulta-

neously increasing the strength of external rotation, is

largely adapting in order to compensate for loss of flexion

strength due to hamstring tendon harvest.

In our series, we harvested a hamstring graft for the

double-bundle ACL reconstruction and PCL reconstruction

was performed using a tibialis allograft. Our results for the

ACL-reconstructed group were similar to those of the

healthy group at 3 months. This result corresponds with

previous results on external rotation moment. However, in

PCL-reconstructed patients, the maximum external rotation

moment and ground reaction force were decreased. Most

biomechanical factors, particularly ground reaction force,

were low. This implied that PCL-reconstructed patients

might be reluctant to engage in or lack strength for per-

formance of daily rotational activities. Therefore, attention

must be given to the post-operative management of PCL-

reconstructed patients.

Most studies on this topic have focused on the return to

daily activities or sports after ACL reconstruction. DeVita

et al. [3] reported that gait biomechanics were not normal

after ACL reconstruction when utilizing accelerated reha-

bilitation 6 months following surgery. In addition, Ti-

money et al. [32] reported that subjects still exhibited gait

differences 1 year after surgery. In our series, we encour-

aged full weight bearing from the immediate postoperation

for the proprioceptive training, limited brace use, and

limited crutch use. With our opinion, these factors

improved proprioception, engagement, and co-strengthen-

ing of musculature and these may contribute to the early

return of patients.

In contrast to ACL rehabilitation, it is generally accep-

ted that accelerated PCL post-operative rehabilitation is

entirely undesirable [5]. The posterolateral rotatory insta-

bility is most commonly combined with PCL injury, and

the posterolateral corner sling (PLCS) reconstruction is

frequently used for posterolateral rotatory instability

because it has several advantages [6, 13]. PLCS recon-

structions could be a continuous spectrum that could be

combined with PCL injury according to the severity of

injury. Main stream of the rehabilitation of PLCS recon-

struction is similar with PCL [5, 11, 23, 29]. Most surgeons

encourage slow rehabilitation after PCL reconstruction [26,

30, 36]. Therefore, evidence is lacking in the literature on

the understanding or existence of compensatory mecha-

nisms for PCL-reconstructed patients, although some data

on PCL deficiency are available [8].

Traditionally, flexion has been limited to 90� for the first

6 weeks of postoperative rehabilitation after PCL recon-

struction, and hamstring strengthening is not initiated until

3 months because of static stability [14, 15, 17]. Thus, the

hamstrings might become weak during the early post-

operative period. Weak hamstrings may lead to a delay in

the hamstring muscle activation that results from an

absence of co-contraction between the quadriceps and

hamstring muscle groups at a time early in the foot strike

[9]. The decrease in extension moment and the increase in

HQ ratio observed in our study might be due to these co-

weaknesses in the hamstring and quadriceps muscles.

Therefore, in our opinion, co-strengthening exercises, such

as calf raising, short arc leg press, and mini-squatting,

could be considered because these exercises produce co-

contraction between the quadriceps and hamstring muscles

with little posterior shear force.


123

Our study had several advantages. First, studies evalu-

ating PCL-reconstructed patients are rare. Second, the

surgeon and biomechanical researcher co-participated in all

experiments in order to ensure the safety of the patients and

the collection of accurate data. Several limitations must

also be considered. First, although the number of patients

was small, the incidence of PCL reconstruction is lower

than that of other ligamentous surgeries, and the sample

size was appropriate based on a power analysis. Second,

we did not measure the muscle power directly. Third, the

experimental period of this study was relatively short for

evaluation of full function; therefore, full recovery may not

have been accomplished in the study period. However, we

chose 3 and 6 months postoperatively because function

during this period is important for early return to daily

activities and work. Fourth, cutting and turn running might

be performed under fatigue conditions and with the ability

to decide whether or not to participate. However, the task

of cutting and turn running in a laboratory produces suf-

ficient rotational torque to initiate rotational instability

[35]. This experiment was conducted in a manner to protect

patient safety; thus, the risk of injury was minimized.

Conclusions

PCL-reconstructed patients showed some biomechanical

deficits in performance of activities that require rotation,

compared to ACL-reconstructed patients. Therefore, the

modification of a rehabilitation programme for PCL-

reconstructed patients would be necessary for improvement

of the biomechanical properties during performance of

dynamic activities.

Acknowledgments This work was supported by the National

Research Foundation of Korea Grant funded by the Korean Govern-

ment (2012000971).

References

1. Ahn JH, Lee YS, Chang MJ, Kum DH, Kim YH (2009) Ana-

tomical graft passage in transtibial posterior cruciate ligament

reconstruction using bioabsorbable tibial cross pin fixation.

Orthopedics 32:96

2. Bell AL, Pedersen DR, Brand RA (1990) A comparison of the

accuracy of several hip center location prediction methods.

J Biomech 23:617–621

3. DeVita P, Hortobagyi T, Barrier J (1998) Gait biomechanics are

not normal after anterior cruciate ligament reconstruction and

accelerated rehabilitation. Med Sci Sports Exerc 30:1481–1488

4. Edson CJ, Fanelli GC, Beck JD (2010) Postoperative rehabilita-

tion of the posterior cruciate ligament. Sports Med Arthrosc

18:275–279

5. Fanelli GC (2008) Posterior cruciate ligament rehabilitation: how

slow should we go? Arthroscopy 24:234–235

6. Fanelli GC (2006) Surgical treatment of lateral posterolateral

instability of the knee using biceps tendon procedures. Sports

Med Arthrosc 14:37–43

7. Goudie EB, Will EM, Keating JF (2010) Functional outcome

following PCL and complex knee ligament reconstruction. Knee

17:230–234

8. Grassmayr MJ, Parker DA, Coolican MR, Vanwanseele B (2008)

Posterior cruciate ligament deficiency: biomechanical and bio-

logical consequences and the outcomes of conservative treatment.

A systematic review. J Sci Med Sport 11:433–443

9. Hewett TE, Myer GD, Ford KR (2006) Anterior cruciate ligament

injuries in female athletes: part 1, mechanisms and risk factors.

Am J Sports Med 34:299–311

10. Houck JR, Duncan A, De Haven KE (2006) Comparison of

frontal plane trunk kinematics and hip and knee moments during

anticipated and unanticipated walking and side step cutting tasks.

Gait Posture 24:314–322

11. Irrgang JJ, Fitzgerald GK (2000) Rehabilitation of the multiple-

ligament-injured knee. Clin Sports Med 19:545–571

12. Jackson WF, van der Tempel WM, Salmon LJ, Williams HA,

Pinczewski LA (2008) Endoscopically-assisted single-bundle

posterior cruciate ligament reconstruction: results at minimum

ten-year follow-up. J Bone Joint Surg Br 90:1328–1333

13. Jung YB, Jung HJ, Kim SJ, Park SJ, Song KS, Lee YS, Lee

SH (2008) Posterolateral corner reconstruction for postero-

lateral rotatory instability combined with posterior cruciate

ligament injuries: comparison between fibular tunnel and tibial

tunnel techniques. Knee Surg Sports Traumatol Arthrosc

16:239–248

14. Jung YB, Jung HJ, Tae SK, Lee YS, Lee KH (2005) Recon-

struction of the posterior cruciate ligament with a mid-third

patellar tendon graft with use of a modified tibial inlay method.

J Bone Joint Surg Am 87(Suppl 1):247–263

15. Jung YB, Jung HJ, Tae SK, Lee YS, Yang DL (2006) Tensioning

of remnant posterior cruciate ligament and reconstruction of

anterolateral bundle in chronic posterior cruciate ligament injury.

Arthroscopy 22:329–338

16. Landry SC, McKean KA, Hubley-Kozey CL, Stanish WD, De-

luzio KJ (2007) Neuromuscular and lower limb biomechanical

differences exist between male and female elite adolescent soccer

players during an unanticipated run and crosscut maneuver. Am J

Sports Med 35:1901–1911

17. Lee YS, Ahn JH, Jung YB, Wang JH, Yoo JC, Jung HJ, Kang BJ

(2007) Transtibial double bundle posterior cruciate ligament

reconstruction using TransFix tibial fixation. Knee Surg Sports

Traumatol Arthrosc 15:973–977

18. Lee YS, Kim NK (2011) Rehabilitation after posterior cruciate

ligament reconstruction. Minerva Orthop Traumatol 62:291–295

19. Lee YS, Kim SK, Park JH, Park JW, Wang JH, Jung YB, Ahn JH

(2007) Double-bundle anterior cruciate ligament reconstruction

using two different suspensory femoral fixation: a technical note.

Knee Surg Sports Traumatol Arthrosc 15:1023–1027

20. Lee YS, Lim BO, Kim JG, Lee KK, Park HO, An KO, Ryew CC,

Kim JH (2011) Serial assessment of knee joint moments in

posterior cruciate ligament and posterolateral corner recon-

structed patients during a turn running task. Arch Orthop Trauma

Surg 131:335–341

21. Lim BO, Lee YS, Kim JG, An KO, Yoo J, Kwon YH (2009)

Effects of sports injury prevention training on the biomechanical

risk factors of anterior cruciate ligament injury in high school

female basketball players. Am J Sports Med 37:1728–1734

22. Lim BO, Lee YS, Kim JG, An KO, Yoo J, Kwon YH (2009)

Effects of sports injury prevention training on the biomechanical

risk factors of anterior cruciate ligament injury in high school

female basketball players. Am J Sports Med 37:1728–1734


123

23. Noyes FR, Barber-Westin SD, Albright JC (2006) An analysis of

the causes of failure in 57 consecutive posterolateral operative

procedures. Am J Sports Med 34:1419–1430

24. Osternig LR, Bates BT, James SL (1980) Patterns of tibial rotary

torque in knees of healthy subjects. Med Sci Sports Exerc

12:195–199

25. Segawa H, Omori G, Koga Y, Kameo T, Iida S, Tanaka M (2002)

Rotational muscle strength of the limb after anterior cruciate

ligament reconstruction using semitendinosus and gracilis tendon.

Arthroscopy 18:177–182

26. Sell TC, Ferris CM, Abt JP, Tsai YS, Myers JB, Fu FH, Lephart

SM (2007) Predictors of proximal tibia anterior shear force dur-

ing a vertical stop-jump. J Orthop Res 25:1589–1597

27. Shelbourne KD, Klootwyk TE, Wilckens JH, De Carlo MS

(1995) Ligament stability two to six years after anterior cruciate

ligament reconstruction with autogenous patellar tendon graft and

participation in accelerated rehabilitation program. Am J Sports

Med 23:575–579

28. Shelbourne KD, Nitz P (1990) Accelerated rehabilitation after

anterior cruciate ligament reconstruction. Am J Sports Med

18:292–299

29. Shelbourne KD, Nitz P (1992) Accelerated rehabilitation after

anterior cruciate ligament reconstruction. J Orthop Sports Phys

Ther 15:256–264

30. Solomonow M, Baratta R, Zhou BH, Shoji H, Bose W, Beck C,

D’Ambrosia R (1987) The synergistic action of the anterior

cruciate ligament and thigh muscles in maintaining joint stability.

Am J Sports Med 15:207–213

31. Stergiou N, Ristanis S, Moraiti C, Georgoulis AD (2007) Tibial

rotation in anterior cruciate ligament (ACL)-deficient and ACL-

reconstructed knees: a theoretical proposition for the develop-

ment of osteoarthritis. Sports Med 37:601–613

32. Timoney JM, Inman WS, Quesada PM, Sharkey PF, Barrack RL,

Skinner HB, Alexander AH (1993) Return of normal gait patterns

after anterior cruciate ligament reconstruction. Am J Sports Med

21:887–889

33. Torry MR, Decker MJ, Jockel JR, Viola R, Sterett WI, Steadman

JR (2004) Comparison of tibial rotation strength in patients’

status after anterior cruciate ligament reconstruction with ham-

string versus patellar tendon autografts. Clin J Sport Med

14:325–331

34. Viola RW, Sterett WI, Newfield D, Steadman JR, Torry MR

(2000) Internal and external tibial rotation strength after anterior

cruciate ligament reconstruction using ipsilateral semitendinosus

and gracilis tendon autografts. Am J Sports Med 28:552–555

35. Waite JC, Beard DJ, Dodd CA, Murray DW, Gill HS (2005)

In vivo kinematics of the ACL-deficient limb during running and

cutting. Knee Surg Sports Traumatol Arthrosc 13:377–384

36. White KK, Lee SS, Cutuk A, Hargens AR, Pedowitz RA (2003)

EMG power spectra of intercollegiate athletes and anterior cru-

ciate ligament injury risk in females. Med Sci Sports Exerc

35:371–376


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Biomechanical comparison of rotational activities between anterior cruciate ligament- and posterior cruciate ligament-reconstructed patients