Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 4, pp 1237–1244 | Cite as

Anterior cruciate ligament graft fixation first in anterior and posterior cruciate ligament reconstruction best restores knee kinematics

  • Libin Zheng
  • Soheil Sabzevari
  • Brandon Marshall
  • Junjun Zhu
  • Monica A. Linde
  • Patrick Smolinski
  • Freddie H. Fu



To evaluate the effect of different graft fixation sequences in one-stage anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction on (1) knee biomechanics and (2) tibiofemoral alignment.


Twelve porcine knees were used in this study. Five fixation sequences were performed (angle indicating knee flexion): (a) PCL at 30° and ACL at 30°, (b) PCL at 90° and ACL at 30°, (c) ACL at 30° and PCL at 30°, (d) ACL at 30° and PCL at 90°, and (e) ACL and PCL simultaneous fixation at 30°. Anterior and posterior tibial translation was measured under an 89 N load. A 3-D digitizer was used to measure the change in anteroposterior (AP) tibiofemoral position.


None of the graft fixation sequences restored the AP laxity of the intact knee, and there are minimal differences in the in situ tissue forces in the ACL and PCL grafts. The reconstructions with fixation of the PCL graft first resulted in a significantly larger change in AP tibiofemoral position from the intact knee at 60° and 90° of knee flexion than the reconstructions with fixation of the ACL graft first (p < 0.05).


Fixation of the ACL graft at 30° of knee flexion followed by fixation of the PCL graft can best restore the tibiofemoral position of the intact knee. This study has clinical relevance in regard to the effect of graft fixation sequence on the position of the tibia relative to the femur in one-stage ACL and PCL reconstruction.


One-stage ACL and PCL reconstruction Multiligamentous injuries Porcine 


Compliance with ethical standards

Conflict of interest

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.


This study was funded by the Department of Orthopedic Surgery at the University of Pittsburgh.

Ethical approval

No ethical approval was required from IACUC.

Informed consent



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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  • Libin Zheng
    • 1
    • 2
  • Soheil Sabzevari
    • 1
    • 3
  • Brandon Marshall
    • 4
  • Junjun Zhu
    • 4
  • Monica A. Linde
    • 1
  • Patrick Smolinski
    • 1
    • 4
  • Freddie H. Fu
    • 1
    • 4
  1. 1.Department of Orthopaedic SurgeryUniversity of PittsburghPittsburghUSA
  2. 2.Department of Orthopaedic SurgeryXiamen Chang Gung HospitalXiamenChina
  3. 3.Department of Orthopedic SurgeryMashhad University of Medical SciencesMashhadIran
  4. 4.Department of Mechanical Engineering and Material ScienceUniversity of PittsburghPittsburghUSA

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