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Biomechanical Function and Size of the Anteromedial and Posterolateral Bundles of the ACL Change Differently with Skeletal Growth in the Pig Model

Cone, Stephanie G. PhD; Lambeth, Emily P. BS; Ru, Hongyu PhD; Fordham, Lynn A. MD; Piedrahita, Jorge A. PhD; Spang, Jeffrey T. MD; Fisher, Matthew B. PhD

Clinical Orthopaedics and Related Research®: September 2019 - Volume 477 - Issue 9 - p 2161–2174
doi: 10.1097/CORR.0000000000000884.

Background ACL injuries are becoming increasingly common in children and adolescents, but little is known regarding age-specific ACL function in these patients. To improve our understanding of changes in musculoskeletal tissues during growth and given the limited availability of pediatric human cadaveric specimens, tissue structure and function can be assessed in large animal models, such as the pig.

Questions/purposes Using cadaveric porcine specimens ranging throughout skeletal growth, we aimed to assess age-dependent changes in (1) joint kinematics under applied AP loads and varus-valgus moments, (2) biomechanical function of the ACL under the same loads, (3) the relative biomechanical function of the anteromedial and posterolateral bundles of the ACL; and (4) size and orientation of the anteromedial and posterolateral bundles.

Methods Stifle joints (analogous to the human knee) were collected from female Yorkshire crossbreed pigs at five ages ranging from early youth to late adolescence (1.5, 3, 4.5, 6, and 18 months; n = 6 pigs per age group, 30 total), and MRIs were performed. A robotic testing system was used to determine joint kinematics (AP tibial translation and varus-valgus rotation) and in situ forces in the ACL and its bundles in response to applied anterior tibial loads and varus-valgus moments. To see if morphological changes to the ACL compared with biomechanical changes, ACL and bundle cross-sectional area, length, and orientation were calculated from MR images.

Results Joint kinematics decreased with increasing age. Normalized AP tibial translation decreased by 44% from 1.5 months (0.34 ± 0.08) to 18 months (0.19 ± 0.02) at 60° of flexion (p < 0.001) and varus-valgus rotation decreased from 25° ± 2° at 1.5 months to 6° ± 2° at 18 months (p < 0.001). The ACL provided the majority of the resistance to anterior tibial loading at all age groups (75% to 111% of the applied anterior force; p = 0.630 between ages). Anteromedial and posterolateral bundle function in response to anterior loading and varus torque were similar in pigs of young ages. During adolescence (4.5 to 18 months), the in situ force carried by the anteromedial bundle increased relative to that carried by the posterolateral bundle, shifting from 59% ± 22% at 4.5 months to 92% ± 12% at 18 months (data for 60° of flexion, p < 0.001 between 4.5 and 18 months). The cross-sectional area of the anteromedial bundle increased by 30 mm2 throughout growth from 1.5 months (5 ± 2 mm2) through 18 months (35 ± 8 mm2; p < 0.001 between 1.5 and 18 months), while the cross-sectional area of the posterolateral bundle increased by 12 mm2 from 1.5 months (7 ± 2 mm2) to 4.5 months (19 ± 5 mm2; p = 0.004 between 1.5 and 4.5 months), with no further growth (17 ± 7 mm2 at 18 months; p = 0.999 between 4.5 and 18 months). However, changes in length and orientation were similar between the bundles.

Conclusion We showed that the stifle joint (knee equivalent) in the pig has greater translational and rotational laxity in early youth (1.5 to 3 months) compared with adolescence (4.5 to 18 months), that the ACL functions as a primary stabilizer throughout growth, and that the relative biomechanical function and size of the anteromedial and posterolateral bundles change differently with growth.

Clinical Relevance Given the large effects observed here, the age- and bundle-specific function, size, and orientation of the ACL may need to be considered regarding surgical timing, graft selection, and graft placement. In addition, the findings of this study will be used to motivate pre-clinical studies on the impact of partial and complete ACL injuries during skeletal growth.

S. G. Cone, E. P. Lambeth, M. B. Fisher, Department of Biomedical Engineering, North Carolina State University and the University of North Carolina – Chapel Hill, Raleigh, NC, USA

S. G. Cone, J. A. Piedrahita, M. B. Fisher, Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA

H. Ru, Department of Computational Biology and Bioinformatics, North Carolina State University, Raleigh, NC, USA

L. A. Fordham, Department of Radiology, University of North Carolina – Chapel Hill, Chapel Hill, NC, USA

J. A. Piedrahita, Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, NC, USA

J. T. Spang, M. B. Fisher, Department of Orthopaedics, University of North Carolina – Chapel Hill, Chapel Hill, NC, USA

M. B. Fisher, North Carolina State University, 4130 Engineering Building III, CB7115, Raleigh, NC, 27695 USA, Email:

The institution or one or more of the authors (SGC, MBF) has received funding from the National Institutes of Health (R03 AR068112, R01 AR071985) and the National Science Foundation (DGE-1252376). Partial support was provided by a National Cancer Institute core grant, P30-CA016086-40. Each author certifies that he or she has no commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the animal protocol of this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at North Carolina State University (functional testing), Raleigh, NC, USA, and the University of North Carolina (MRI), Chapel Hill, NC, USA.

Received November 09, 2018

Accepted June 13, 2019

Online date: August 14, 2019

© 2019 Lippincott Williams & Wilkins LWW
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