Contents Abstract (Chinese)…………….…………………………..………………..…………..…I Abstract…………………………………………………………………………………..III Acknowledgement……………………………………………………………………….. V. Contents…………………………………………………………………………………..Ⅵ List of Tables……………………………………………………………………………VIII List of Figures……………………………………………………………………….........Ⅸ Chapter 1……………………………………………………………………………….1 INTRODUCTION 1.1 Preface…………………………………………………………………………… 1 1.2 Clinical and Literature Review…………………………………………………….. 3 1.2.1 Anatomy…………………………………………………………………… 3 1.2.2 Knee Injury and the Treatment…………………………………………….. 7 1.2.3 Surgical Operations………………………………………………………… 8 1.2.4 Knee Kinematics and the Forces on the ACL……………………………… 9 1.3 Motivations and Purposes………………………………………………………. 13 Chapter 2…………………………………………………………………………………15 MATERIALS AND METHODS 2.1 Specimen Preparation………………….…………………………………………. 15 2.2 Experimental Instrumentation………………………………………………….. 17 2.2.1 Material Testing System………………………………………………….. 17 2.2.2 Clamp…………………………………………………………………….. 19 2.2.3 InstruNet External A/D Box and PC-Card Controller………………….… 21 2.3 Experimental Procedure……………………………………………………..…. 23 2.3.1 Mechanical Testing on the Intact Knee…………………………………... 24 2.3.2 Mechanical Testing on the ACL Sectioning…………………………….... 26 2.3.3 Mechanical Testing on the ACL Surgery……………………………….... 27 2.3.4 Data Collection and Processing………………………………………….. 30 2.3.5 Evaluation of the Specimens after the Mechanical Testing…………….... 31 2.4 Experimental Protocols…………………………………………………………. 31 2.5 Statistical Analysis…………………………………………………………..….. 32 Chapter 3………….…………………………………………………………………….. 33 RESULTS………………………………………………………………………………. 33 3.1 Knee Laxity…………………………………………………………………….… 34 3.1.1 Neutral Position………………………………………………………………. 34 3.1.2 Internal Rotation Position…………………………………………………….. 39 3.1.3 External Rotation Position……………………………………………………. 45 3.1.4 Comparison between Two Surgical Operations……………………………… 50 3.2 Loading History………………………………………………………………..… 54 3.2.1 Time to Peak Force and the Relative Loading Period………………………… 55 3.2.2 Relationship of Displacement-Force-Time between Two Surgical Operations…59 3.3 Evaluation of the Specimens after the Mechanical Testing……………………… 65 Chapter 4………………………………………………………………………………... 66 DISCUSSION 4.1 Anterior Knee Laxity…………………………………………………………….. 66 4.1.1 ACL cut and repair……………………………………………………………. 66 4.1.2 Knee Flexion Angle…………………………………………………………... 67 4.1.3 Tibial Position………………………………………………………………… 67 4.1.4 Conventional v.s. Innovative Techniques…………………………………….. 69 4.2 Comparison with Other Studies………………………………………………….. 69 4.3 Limitations……………………………………………………………………….. 69 Chapter 5………………………………………………………………………………... 72 CONCLUSION REFERENCES………………………………………………...………………………. 74 APPENDIX The Detail Kinematics Data of the Porcine Knee Cadavers ……………………….. 77 List of Tables Table 3.1.a……………………………………………………………………………………35 Tibia in neutral position Table 3.1.b……………………………………………………………………………………36 Tibia in neutral position Table 3.2.a, b…………………………………………………………………………………41 Tibia in internal position Table 3.3.a……………………………………………………………………………………46 Tibia in internal position Table 3.3.b……………………………………………………………………………………47 Tibia in internal position Table 3.4………………………………………………………………………………………53 Check list of the Normal Distribution Table 3.5…………………………………………………………………………………….53 Results of statistical analysis (Mean Knee Laxity) Table 3.6…………………………………………………………………………………….54 Results of statistical analysis (Laxity Recovery Ratio) Table3.7…………………………………………………………………………………..59 Summary of time of peak force and the relative loading period List of Figures Fig.1-1………………………………………………………………………………………4 Anterior view of the knee Fig.1-2………………………………………………………………………………………5 The anatomy of the flexed knee showing the cruciate ligaments Fig.1-3.a…………………………………………………………………………………….5 Drawing of the posterior surface of the tibia (A) and the upper surface of the tibial plateau (B) Fig. 1-3.b……………………………………………………………………………………6 When the knee is extended, both ACL and PCL become taut and help lock the knee into a rigid structure Fig. 1-3.c……………………………………………………………………………………6 When the knee is flexed or extended, the ACL prevents anterior slipping movements of the tibia, whereas the PCL prevents posterior slipping movements Fig. 1-4.a…………………………………………………………………………………..10 Anterior drawer Test Fig. 1-4.b……………………………………………………………………………………..10 Lachman Test Fig.1-4.c Pivot-shift Testing…………………………………………………………………………11 Fig. 2-1………………………………………………………………………………………..15 Approximately 15 cm above and below the knee joint were cut Fig. 2-2………………………………………………………………………………………..16 The skins and the muscles were dissected away, only leaving ligaments, meniscus, and the joint capsules Fig. 2-3……………………………………………………………………………………..16 The tibia were potted with PMMA Fig. 2-4………………………………………………………………………………………..17 The designed aluminum cylinder Fig. 2-5………………………………………………………………………………………..17 The finish of the specimen preparation Fig. 2-6………………………………………………………………………………………..18 Material Testing System Fig. 2-7.a………………………………………………………………………………………19 A six degrees of freedom testing apparatus described by Fleming et al. Fig 2-7.b………………………………………………………………………………………19 The design of the clamp and the completion of the clamp Fig 2-8………………………………………………………………………………………20 The extra force/torque sensor with the tibial yoke attached with a shaft and the completion of the clamp attached with MTS Fig. 2-9……………………………………………………………………………………..…21 The six degrees of freedom of the knee joint Fig. 2-10……………………………………………………………………………………….22 The completion of the extra force/moment senor set-up Fig. 2-11.a………………………………………………………………………………….22 The completion of the specimen preparation and the clamp set-up Fig. 2-11.b………………………………………………………………………………….22 The anterior view of the completion set up Fig. 2-12……………………………………………………………………………………23 The loading process Fig. 2-13.a-e………………………………………………………………………………..25 The set-up of the specimen before testing Fig. 2-14.a………………………………………………………………………………….28 The design of conventional pull-out technique Fig. 2-14.b………………………………………………………………………………….28 The design of SSSAS Fig. 2-15.a………………………………………………………………………………….29 Cut ACL Fig. 2-15.b………………………………………………………………………………….29 Repair ACL in pullout technique Fig. 2-15.c………………………………………………………………………………….29 Repair ACL in SSSAS technique Fig. 3.1……………………………………………………………………………………..36 Mean knee laxity between intact and repaired knees in pullout group Fig. 3.2……………………………………………………………………………………..37 Mean knee laxity between intact and repaired knee in SSSAS group Fig. 3.3……………………………………………………………………………………...37 Mean knee laxity at 4 flexion angles among 3 knee conditions in pullout group Fig. 3.4……………………………………………………………………………………...38 Mean knee laxity at 4 flexion angles among 3 knee conditions in SSSAS group Fig. 3.5……………………………………………………………………………………...38 Mean knee laxity between two surgical techniques Fig. 3.6……………………………………………………………………………………...39 Laxity recovery ratio between two surgical techniques Fig. 3.7……………………………………………………………………………………...42 Mean knee laxity between intact and repaired knee in pullout group Fig. 3.8……………………………………………………………………………………...42 Mean knee laxity between intact and repaired knee in SSSAS group Fig. 3.9…………………………………………………………...…………………………43 Mean knee laxity at 4 flexion angles among 3 knee conditions in pullout group Fig. 3.10……………………………………………………………………………………43 Mean knee laxity at 4 flexion angles among 3 knee conditions in SSSAS Group Fig. 3.11…………………………………………………………………………………….44 Mean knee laxity between two surgical techniques Fig. 3.12……………………………………………………………………………………44 Laxity recovery ratio between two surgical techniques Fig. 3.13……………………………………………………………………………………47 Mean knee laxity between intact and repaired knee in pullout group Fig. 3.14……………………………………………………………………………………48 Mean knee laxity between intact and repaired knee in SSSAS group Fig. 3.15……………………………………………………………………………………48 Mean knee laxity at 4 flexion angles among 3 knee conditions in pullout Group Fig. 3.16……………………………………………………………………………………49 Mean knee laxity at 4 flexion angles among 3 knee conditions in SSSAS Group Fig. 3.17……………………………………………………………………………………49 Mean knee laxity between two surgical techniques Fig. 3.18……………………………………………………………………………………50 Laxity recovery ratio between two surgical techniques Fig. 3.19……………………………………………………………………………………51 Laxity differences between two surgeries in neutral position Fig. 3.20……………………………………………………………………………………51 Laxity differences between two surgeries in internal rotation position Fig. 3.21………………………………………….………………………………………...52 Laxity differences between two surgeries in external rotation position Fig. 3-22.a………………………………………………………………………………….56 Tibia in neutral position Fig. 3-22.b………………………………………………………………………………….56 Tibia in internal position Fig. 3-22.c………………………………………………………………………………….57 Tibia in external position Fig. 3-23.a………………………………………………………………………………….57 ACL-intact Knee Fig. 3-23.b………………………………………………………………………………….58 ACL-cut knee Fig. 3-23.c………………………………………………………………………………….58 ACL-repaired knee Fig.3.24.a ……………………………………………………………………………….60 Diagram of displacement-time between two surgical operations under ACL-intact condition during mechanical testing Fig.3.24.b………………………………………………………………………………..60 Diagram of force-time between two surgical operations under ACL-intact condition during mechanical testing Fig.3.24.c…………………………………………………………………………………..61 Diagram of force-displacement between two surgical operations under ACL-intact condition during mechanical testing Fig.3.25.a ……………………………………………………………………………….61 Diagram of displacement-time between two surgical operations under ACL-cut condition during mechanical testing Fig.3.25.b ……………………………………………………………………………….62 Diagram of force-time between two surgical operations under ACL-cut condition during mechanical testing Fig.3.25.c ………………………………………………………………………………….62 Diagram of force-displacement between two surgical operations under ACL-cut condition during mechanical testing Fig.3.26.a ……………………………………………………………………………….63 Diagram of displacement-time between two surgical operations under ACL-repaired condition during mechanical testing Fig.3.26.b ……………………………………………………………………………….63 Diagram of force-time between two surgical operations under ACL-repaired condition during mechanical testing Fig.3.25.c ………………………………………………………………………………….64 Diagram of force-displacement between two surgical operations under ACL-repaired condition during mechanical testing Fig. 3-27……………………………………………………………………………………65 After the testing－the pullout group vs. the SSSAS group