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Castro MO, Baptista DC, Afonso PD. Demystifying the "Dark Side of the Knee": An Update on Imaging of the Posterolateral Corner. Semin Musculoskelet Radiol 2024; 28:305-317. [PMID: 38768595 DOI: 10.1055/s-0044-1781431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
The posterolateral corner (PLC) of the knee is a complex anatomical-functional unit that includes ligamentous and tendinous structures that are crucial for joint stability. This review discusses the intricate anatomy, biomechanics, and imaging modalities, as well as the current challenges in diagnosing PLC injuries, with an emphasis on magnetic resonance imaging (MRI). Recognizing the normal MRI anatomy is critical in identifying abnormalities and guiding effective treatment strategies. Identification of the smaller structures of the PLC, traditionally difficult to depict on imaging, may not be necessary to diagnose a clinically significant PLC injury. Injuries to the PLC, often associated with cruciate ligament tears, should be promptly identified because failure to recognize them may result in persistent instability, secondary osteoarthritis, and cruciate graft failure.
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Affiliation(s)
- Miguel Oliveira Castro
- Radiology Department, Centro Hospitalar Universitário do Algarve, Portimão, Portugal
- Lagoa Centro - Imagens Médicas, Lagoa, Portugal
| | - Diogo Correia Baptista
- Radiology Department, Instituto Português de Oncologia Francisco Gentil, Lisbon, Portugal
| | - P Diana Afonso
- Musculoskeletal Imaging Unit, Radiology Department, Hospital da Luz, Grupo Luz Saúde, Lisbon, Portugal
- Radiology Department, Hospital Particular da Madeira, Grupo HPA, Funchal, Portugal
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2
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Ryu JH, Lee SW, Lee DH. An all-arthroscopic surgery technique for snapping popliteal tendon syndrome: A case report and literature review. Medicine (Baltimore) 2022; 101:e31347. [PMID: 36343076 PMCID: PMC9646570 DOI: 10.1097/md.0000000000031347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
RATIONALE The incidence of snapping popliteus tendon syndrome, a type of lateral knee snapping, is not high, so making an accurate diagnosis is difficult. A proper treatment following an accurate diagnosis is essential for improvement. Very few cases have been reported of its treatment. PATIENT CONCERNS An 18-year-old male patient had experienced painful popping in the lateral part of the knee during knee flexion for 3 years before his hospital visit. DIAGNOSES Snapping popliteus tendon syndrome. INTERVENTIONS The patient underwent an all-arthroscopic surgery. Tendon debulking and tissue debridement around the popliteus tendon was conducted, but the snapping did not resolve. The enlarged tubercle was excised through an arthroscopic procedure using a burr, and the surgery was finished after confirming that snapping was resolved. OUTCOMES Full range of motion (ROM) was recovered 6 weeks after surgery and the snapping did not recur. LESSONS Snapping popliteus tendon syndrome is a disease that is hardly recognized due to its low prevalence and difficulty in diagnosis, and it requires close observation of the patient before surgery. The location of the tenderness and the snapping occurrence must also be carefully identified. Our procedure is an entirely arthroscopic technique; as it has the prominent advantage of a speedy recovery and easy rehabilitation, it could also be helpful to set treatment standards for this disease in the future.
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Affiliation(s)
- Ji Hyun Ryu
- Department of Orthopedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Se-Won Lee
- Department of Orthopedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Hwan Lee
- Department of Orthopedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * Correspondence: Dong Hwan Lee, Department of Orthopedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeongdeungpo-gu, Seoul 07345, Republic of Korea (e-mail: )
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Hodel S, Hasler J, Fürnstahl P, Fucentese SF, Vlachopoulos L. Elongation Patterns of Posterolateral Corner Reconstruction Techniques: Results Using 3-Dimensional Weightbearing Computed Tomography Simulation. Orthop J Sports Med 2022; 10:23259671221090219. [PMID: 35464904 PMCID: PMC9019341 DOI: 10.1177/23259671221090219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background: The isometric characteristics of nonanatomic and anatomic posterolateral corner (PLC) reconstruction techniques under weightbearing conditions remain unclear. Purpose: To (1) simulate graft elongation patterns during knee flexion for 3 different PLC reconstruction techniques (Larson, Arciero, and LaPrade) and (2) compute the most isometric insertion points of the fibular collateral ligament (FCL) graft strands for each technique and report quantitative radiographic landmarks. Study Design: Descriptive laboratory study. Methods: The authors performed a 3-dimensional simulation of 10 healthy knees from 0° to 120° of flexion using weightbearing computed tomography (CT) scans. The simulation was used to calculate ligament length changes during knee flexion for the PLC reconstruction techniques of Larson (nonanatomic single-bundle fibular sling reconstruction), Arciero (anatomic reconstruction with additional popliteofibular ligament graft strand), and LaPrade (anatomic reconstruction with popliteofibular ligament graft strand and popliteus tendon graft strand). The most isometric femoral insertion points for the FCL graft strands were computed within a 10-mm radius around the lateral epicondyle (LE), using an automatic string generation algorithm (0 indicating perfect isometry). Radiographic landmarks for the most isometric points were reported. Results: Median graft lengthening during knee flexion was similar for the anterior graft strands of all 3 techniques. The posterior graft strands demonstrated significant differences, from lengthening for the Arciero (9.9 mm [range, 6.7 to 15.9 mm]) and LaPrade (10.2 mm [range, 4.1 to 19.7 mm]) techniques to shortening for the Larson technique (−17.1 mm [range, −9.3 to −22.3 mm]; P < .0010). The most isometric point for the FCL graft strands of all techniques was located at a median of 2.2 mm (range, −2.2 to 4.5 mm) posterior and 0.3 mm (range, −1.8 to 3.7 mm) distal to the LE. Conclusion: Overconstraint can be avoided by tensioning the posterior graft strands in the Larson technique in extension, and in the Arciero and LaPrade techniques at a minimum of 60° of knee flexion. The most isometric point was located posterodistal to the LE. Clinical Relevance: The described isometric behavior of nonanatomic and anatomic PLC reconstruction techniques can guide optimal surgical reconstruction and prevent graft lengthening and overconstraint of the lateral compartment in knee flexion. Repetitive graft lengthening has been found to be associated with graft failure, and overconstraint favors lateral compartment pressure and cartilage degeneration.
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Affiliation(s)
- Sandro Hodel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Julian Hasler
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Philipp Fürnstahl
- Research in Orthopedic Computer Science (ROCS), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Sandro F. Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Vieira ELC, Vieira EÁ, Aguiar RA, Lopes CS, Steffen AM, Cohen M. Are the popliteofibular ligament, the arcuate ligament, and the fibular insertion of the popliteus muscle the same structure? An anatomic and terminological study. J Anat 2022; 241:478-483. [PMID: 35396715 DOI: 10.1111/joa.13663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/18/2022] [Accepted: 03/18/2022] [Indexed: 12/01/2022] Open
Abstract
Lesions in the lateral region of the knee can result in severe disability due to instability and articular degeneration. The structures in the posterolateral side of the knee function as a unit contributes to rotation and translation limits. Anatomical descriptions of the lateral corner of the knee are incomplete and contradictory. This study aims to verify, through anatomical dissections in cadavers, if the fibular insertion of the popliteus muscle, the arcuate ligament, and the popliteofibular ligament are distinct or the same structure with different terminology and descriptions in the literature. Fifteen cadavers were dissected. Photographs were taken, and in some cases, a video was recorded. Also, the correct terminology for ligament and insertion was searched. The dissections allowed the popliteus muscle to be identified proximally in the lateral femoral condyle, in the fibula head's posterolateral region, and through a meniscocapsular insertion. In none of the anatomy books reviewed, this fibular insertion of the popliteus muscle is mentioned. However, our findings and data from other experimental studies provide evidence of its presence. The aponeurotic portion of the arcuate ligament is distinguished from the short lateral ligament, which is the fibular insertion of the popliteus muscle with its tendinous attachment. Therefore, the term popliteofibular ligament should be abandoned based on the anatomic terminology, and the term "fibular insertion of the popliteus muscle" should be used instead.
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Affiliation(s)
- Eduardo Luis Cruells Vieira
- Medical and Biological Sciences Center, Pontifícia Universidade Católica de São Paulo (PUC-SP) in Sorocaba, São Paulo, Brazil
| | - Eduardo Álvaro Vieira
- Medical and Biological Sciences Center, Pontifícia Universidade Católica de São Paulo (PUC-SP) in Sorocaba, São Paulo, Brazil
| | - Rafael Angelini Aguiar
- Former Residents at the Medical and Biological Sciences Center, Pontifícia Universidade Católica de São Paulo (PUC-SP) in Sorocaba, São Paulo, Brazil
| | - Cladis Sanches Lopes
- Former Residents at the Medical and Biological Sciences Center, Pontifícia Universidade Católica de São Paulo (PUC-SP) in Sorocaba, São Paulo, Brazil
| | - Alfredo Mendes Steffen
- Former Residents at the Medical and Biological Sciences Center, Pontifícia Universidade Católica de São Paulo (PUC-SP) in Sorocaba, São Paulo, Brazil
| | - Moisés Cohen
- Sports Traumatology Center (Cete) and Department of Orthopedics and Traumatology at the Universidade Federal de São Paulo (UNIFESP-EPM), São Paulo, Brazil
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5
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MR Imaging of the Knee Posterolateral and Posteromedial Corner Injuries. Magn Reson Imaging Clin N Am 2022; 30:215-226. [DOI: 10.1016/j.mric.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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6
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Boyd ED, Endres NK, Geeslin AG. Surgically Relevant Biomechanics of the Medial and Posterolateral Knee and their Implications on Knee Kinematics and Cruciate Ligament Reconstructions. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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7
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Olewnik Ł, Gonera B, Kurtys K, Zielinska N, Ruzik K, Aragonés P, Sanudo JR, Danowska-Klonowska D, LaPrade RF. Classification of the popliteofibular ligament. Clin Anat 2022; 35:375-382. [PMID: 35119143 DOI: 10.1002/ca.23842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/03/2022] [Accepted: 01/26/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE The purpose of this study was to characterize the morphological variations in the distal attachment of the popliteofibular ligament (PFL) and create an accurate classification for use in planning surgical procedures in this area and in evaluating radiological imaging. METHODS One hundred and thirty-seven lower limbs of body donors fixed in 10% formalin solution were examined for the presence and course of the popliteofibular ligament. RESULTS The PFL was present in 88.3% of cases. We propose the following three-fold classification: type I (72.3%), the most common type, characterized by the attachment onto the apex of the head of the fibula, type II (8.7%), characterized by a bifurcation, with the dominant band inserting on the anterior slope of the styloid process of the fibula and the smaller band onto the posterior surface of the styloid process of the fibula and type III (7.3%), characterized by a double PFL: the first PFL (main) originated from the popliteus tendon and inserted onto the anterior slope of the styloid process of the fibula, while the second originated from the musculotendinous junction of the popliteus muscle and inserted on the posterior surface of the styloid process of the fibula. CONCLUSION The PFL was characterized by high morphological variation, as reflected in our proposed classification. This variation may present clinical and biomechanical issues for both medical personnel and researchers. Our proposed classification may be valuable for clinicians who evaluate and perform surgical procedures within the knee joint area.
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Affiliation(s)
- Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - Bartosz Gonera
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - Konrad Kurtys
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - Nicol Zielinska
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - Kacper Ruzik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Poland
| | - Paloma Aragonés
- Department of Orthopedics Surgery, Hospital Santa Cristina, Madrid, Spain.,Department of Human Anatomy and Embryology, Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - J Ramón Sanudo
- Department of Human Anatomy and Embryology, Facultad de Medicina, Universidad Complutense de Madrid, Spain
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8
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Pękala PA, Mann MR, Pękala JR, Tomaszewski KA, LaPrade RF. Evidence-Based Clinical Anatomy of the Popliteofibular Ligament and Its Importance in Orthopaedic Surgery: Cadaveric Versus Magnetic Resonance Imaging Meta-analysis and Radiological Study. Am J Sports Med 2021; 49:1659-1668. [PMID: 33017542 DOI: 10.1177/0363546520950415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The popliteofibular ligament (PFL) is a static stabilizer of the posterolateral corner of the knee, preventing varus angulation, tibial rotation, and posterior translation. The PFL is anatomically variable, and there is no current review that outlines its prevalence rate and morphological variations. PURPOSE To investigate the anatomic prevalence and morphological qualities of the PFL in various global patient populations via a meta-analysis of relevant literature involving both cadaveric dissections and patient-based research using magnetic resonance imaging (MRI) scans. STUDY DESIGN Meta-analysis. METHODS We pooled literature data detailing PFL prevalence rates and performed a retrospective MRI study of 100 knees to determine the overall PFL prevalence. Data searches and analyses were performed according to Anatomical Quality Assurance and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS There were 30 cadaveric studies and 11 MRI studies (including our radiological investigation), representing a total of 1595 lower limbs. The meta-analysis of cadaveric studies showed a higher prevalence of the PFL than the meta-analysis of MRI studies, with 98.4% (95% CI, 97.5%-99.2%) and 89.0% (95% CI, 73.9%-98.6%), respectively. Our MRI investigation reported a PFL prevalence of 92.0%. CONCLUSION The PFL was found to be a constant or rarely absent anatomic structure of the human knee according to the analysis of cadaveric dissection studies, and it was identified notably less on MRI, albeit not significantly. Increasing PFL anatomic knowledge, including awareness of its prevalence and morphological diversity, will improve injury diagnoses, treatment methods, and prognoses.
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Affiliation(s)
- Przemysław A Pękala
- International Evidence-Based Anatomy Working Group, Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland.,Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
| | - Mitchell R Mann
- International Evidence-Based Anatomy Working Group, Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Jakub R Pękala
- International Evidence-Based Anatomy Working Group, Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Krzysztof A Tomaszewski
- International Evidence-Based Anatomy Working Group, Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland.,Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
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9
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Multi-color and Multi-Material 3D Printing of Knee Joint models. 3D Print Med 2021; 7:12. [PMID: 33914200 PMCID: PMC8082874 DOI: 10.1186/s41205-021-00100-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/15/2021] [Indexed: 01/17/2023] Open
Abstract
Objective This study reports on a new method for the development of multi-color and multi-material realistic Knee Joint anatomical models with unique features. In particular, the design of a fibers matrix structure that mimics the soft tissue anatomy. Methods Various Computer-Aided Design (CAD) systems and the PolyJet 3D printing were used in the fabrication of three anatomical models wherein fibers matrix structure is mimicked: (i) Anterior cruciate ligament reconstruction (ACL-R) model used in the previous study. (ii) ACL-R model, incorporating orientations, directions, locations, and dimensions of the tunnels, as well as a custom-made surgical guide (SG) for avoiding graft tunnel length mismatch. (iii) Total knee arthroplasty (TKA) model, including custom-made implants. Before models 3D printing, uni-axial tensile tests were conducted to obtain the mechanical behaviors for individual No. 1 (A60-A50), No. 2 (A50-A50), No. 3 (A50-A40), and No. 4 (A70-A60) soft tissue-mimicking polymers. Each material combination represents different shore-hardness values between fiber and matrix respectively. Results We correlated the pattern of stress-strain curves in the elastic region, stiffness, and elastic modulus of proposed combinations with published literature. Accordingly, material combinations No. 1 and No. 4 with elastic modules of 0.76-1.82 MPa were chosen for the soft tissues 3D printing. Finally, 3D printing Knee Joint models were tested manually simulating 50 flexo-extension cycles without presenting ruptures. Conclusion The proposed anatomical models offer a diverse range of applications. These may be considered as an alternative to replacing cadaver specimens for medical training, pre-operative planning, research and education purposes, and predictive models validation. The soft tissue anatomy-mimicking materials are strong enough to withstand the stretching during the flexo-extension. The methodology reported for the design of the fiber-matrix structure might be considered as a start to develop new patterns and typologies that may mimic soft tissues.
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Kahan JB, Li D, Schneble CA, Huang P, Bullock J, Porrino J, Medvecky MJ. The Pathoanatomy of Posterolateral Corner Ligamentous Disruption in Multiligament Knee Injuries Is Predictive of Peroneal Nerve Injury. Am J Sports Med 2020; 48:3541-3548. [PMID: 33074710 DOI: 10.1177/0363546520962503] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A description of the precise locations of ligamentous and myotendinous injury patterns of acute posterolateral corner (PLC) injuries and their associated osseous and neurovascular injuries is lacking in the literature. PURPOSE To characterize the ligamentous and myotendinous injury patterns and zones of injury that occur in acute PLC injuries and determine associated rates of peroneal nerve palsies and vascular injuries, as well as fracture and dislocation. STUDY DESIGN Case series; Level of evidence, 4. METHODS We retrospectively identified all patients treated for an acute multiligament knee injury (MLKI) at our level 1 trauma center from 2001 to 2018. From this cohort, all patients with PLC injuries were identified. Demographics, involved ligaments and tendons, neurovascular injury, and presence of fracture and dislocation were compared with the larger multiligament knee cohort. Incidence and location of injury of PLC structures-from proximal to midsubstance and distal injury-were recorded. RESULTS A total of 100 knees in 100 patients were identified as having MLKIs. A total of 74 patients (74%) had lateral-sided ligament injuries. Of these, 23 (31%) had a peroneal nerve palsy associated with their injury; 10 (14%), a vascular injury; and 23 (31%), a fracture. Patients with PLC injuries had higher rates of peroneal nerve injury as compared with those having acute MLKIs without a PLC injury (31% vs 4%; P = .005). Patients with a complete peroneal nerve palsy (n = 17) were less likely to regain function than those with a partial peroneal nerve palsy (n = 6; 12% vs 100%; P < .0001). Complete injury to the lateral collateral ligament (LCL) occurred in 71 of 74 (96%) PLC injuries, with 3 distinct patterns of injury demonstrated. Fibular avulsion of the LCL was the most common zone of injury (65%), followed by femoral avulsion (20%) and midsubstance tear (15%). Location of injury to the LCL was associated with the rate of peroneal nerve injury, with midsubstance tears and fibular avulsions associated with higher rates of peroneal nerve injury. CONCLUSION MLKIs with involvement of the PLC are more likely to suffer peroneal nerve injury. The LCL is nearly always involved, and its location of injury is predictive of peroneal nerve injury. Patients with a complete peroneal nerve palsy at presentation are much less likely to regain function.
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Affiliation(s)
- Joseph B Kahan
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Don Li
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Christopher A Schneble
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Patrick Huang
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - James Bullock
- Orthopaedic Center of South Florida, Fort Lauderdale, Florida, USA
| | - Jack Porrino
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael J Medvecky
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
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Swinford ST, LaPrade R, Engebretsen L, Cohen M, Safran M. Biomechanics and physical examination of the posteromedial and posterolateral knee: state of the art. J ISAKOS 2020. [DOI: 10.1136/jisakos-2018-000221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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12
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Vezeridis PS, Engler ID, Salzler MJ, Hosseini A, Gwathmey FW, Li G, Gill TJ. Biomechanics Following Isolated Posterolateral Corner Reconstruction Comparing a Fibular-Based Docking Technique With a Tibia and Fibular-Based Anatomic Technique Show Either Technique is Acceptable. Arthroscopy 2020; 36:1376-1385. [PMID: 31862293 DOI: 10.1016/j.arthro.2019.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 12/06/2019] [Accepted: 12/08/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the biomechanical integrity of 2 posterolateral corner (PLC) reconstruction techniques using a sophisticated robotic biomechanical system that enables analysis of joint kinematics under dynamic external loads. METHODS Eight cadaveric human knee specimens were tested. Five N·m external torque followed by 5 N·m varus torque was dynamically applied to each specimen. The 6 degrees of freedom kinematics of the joint were measured in 4 states (intact, PLC-deficient, fibular-based docking, and anatomic PLC reconstructed) at 30°, 60°, and 90° of flexion. Tibial external rotation (ER) and varus rotation (VR) were compared. RESULTS Under external torque, ER significantly increased from the intact state to the PLC-deficient state across all flexion angles. At 30° of flexion, ER was not significantly different between the intact state (19.9°) and fibular-based (18.7°, P = .336) and anatomic reconstructions (14.9°, P = .0977). At 60°, ER was not significantly different between the intact state and fibular-based reconstruction (22.4°, compared with 19.8° in intact; P = .152) but showed overconstraint after anatomic reconstruction (15.7°; P = .0315). At 90°, ER was not significantly different between the intact state and anatomic reconstruction (15.4°, compared with 19.7° in intact; P = .386) but was with the fibular-based technique (23.5°; P = .0125). CONCLUSION Both a fibular-based docking technique and an anatomic technique for isolated PLC reconstruction provided appropriate constraint through most tested knee range of motion, yet the fibular-based docking technique underconstrained the knee at 90°, and the anatomic reconstruction overconstrained the knee at 60°. Biomechanically, either technique may be considered for surgical treatment of high-grade isolated PLC injuries. CLINICAL RELEVANCE This biomechanical study utilizing clinically-relevant dynamic forces on the knee shows that either a simplified fibular-based docking technique or a more complex anatomic technique may be considered for surgical treatment of high-grade isolated PLC injuries.
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Affiliation(s)
- Peter S Vezeridis
- Orthopaedic Specialists, Woburn, Massachusetts, United States of America
| | - Ian D Engler
- Tufts Medical Center, Department of Orthopaedics, Boston, Massachusetts, United States of America
| | - Matthew J Salzler
- Tufts Medical Center, Department of Orthopaedics, Boston, Massachusetts, United States of America.
| | - Ali Hosseini
- Massachusetts General Hospital, Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - F Winston Gwathmey
- University of Virginia, Department of Orthopaedic Surgery, Charlottesville, Virginia, United States of America
| | - Guoan Li
- Massachusetts General Hospital, Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Thomas J Gill
- Boston Sports Medicine, Dedham, Massachusetts, United States of America
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Anatomic, All-Arthroscopic Reconstruction of Posterolateral Corner of the Knee: A Cadaveric Biomechanical Study. Arthroscopy 2020; 36:1121-1131. [PMID: 31980202 DOI: 10.1016/j.arthro.2019.10.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 10/23/2019] [Accepted: 10/27/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the role of anatomic reconstruction of the posterolateral corner (PLC) of the knee arthroscopically in cadaveric knees with simulated isolated grade III posterolateral instability. METHODS A total of 12 nonpaired, fresh-frozen cadaveric knees were biomechanically subjected to a 10-Nm varus moment, 5-Nm external and internal rotation torques, and 134-N posterior tibial load at 0°, 15°, 30°, 60°, and 90° of knee flexion (0° for varus loading only). Testing was performed with an intact and sectioned PLC and after anatomic reconstruction of the PLC by an arthroscopic technique. Kinematics of each knee under various loading conditions was determined with a robotic universal force/moment sensor testing system. RESULTS After sectioning, significant increases were found in varus rotation at 0°, 15°, 30°, 60°, and 90° of knee flexion; in external rotation at 15°, 30°, 60°, and 90° of knee flexion; in internal rotation at 60° of knee flexion only; and in posterior translation at 15° and 30° of knee flexion. After reconstruction, full recovery of knee stability was observed in varus rotation, external rotation, internal rotation, and posterior translation at all selected flexion angles without any overconstraint of knee kinematics. CONCLUSIONS Anatomic reconstruction of the PLC can be performed arthroscopically with isolated grade III posterolateral instability of the knee, and nearly normal stability of the knee can be restored. CLINICAL RELEVANCE PLC reconstruction by an anatomic, all-arthroscopic technique achieves optimal stability control and kinematics of the knee.
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Abstract
Knee and leg injuries are extremely common presentations to the emergency department. Understanding the anatomy of the knee, particularly the vasculature and ligamentous structures, can help emergency physicians (EPs) diagnose and manage these injuries. Use of musculoskeletal ultrasonography can further aid EPs through the diagnostic process. Proper use of knee immobilizers can also improve long-term patient outcomes.
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Affiliation(s)
- Moira Davenport
- Department of Emergency Medicine, Allegheny General Hospital, Temple University School of Medicine, 320 East North Avenue, Pittsburgh, PA 15212, USA.
| | - Matthew P Oczypok
- Department of Emergency Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
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15
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An open-source plugin for OpenSim® to model the non-linear behaviour of dense connective tissues of the human knee at variable strain rates. Comput Biol Med 2019; 110:186-195. [DOI: 10.1016/j.compbiomed.2019.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 12/30/2022]
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16
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Kang KT, Koh YG, Nam JH, Jung M, Kim SJ, Kim SH. Biomechanical evaluation of the influence of posterolateral corner structures on cruciate ligaments forces during simulated gait and squatting. PLoS One 2019; 14:e0214496. [PMID: 30947292 PMCID: PMC6448852 DOI: 10.1371/journal.pone.0214496] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 03/14/2019] [Indexed: 01/12/2023] Open
Abstract
Posterolateral corner (PLC) structures of the knee joint comprise complex anatomical soft tissues that support static and dynamic functional movements of the knee. Most previous studies analyzed posterolateral stability in vitro under static loading conditions. This study aimed to evaluate the contributions of the lateral (fibular) collateral ligament (LCL), popliteofibular ligament (PFL), and popliteus tendon (PT) to cruciate ligament forces under simulated dynamic loading conditions by using selective individual resection. We combined medical imaging and motion capture of healthy subjects (four males and one female) to develop subject-specific knee models that simulated the 12 degrees of freedom of tibiofemoral and patellofemoral joint behaviors. These computational models were validated by comparing electromyographic (EMG) data with muscle activation data and were based on previous experimental studies. A rigid multi-body dynamics simulation using a lower extremity musculoskeletal model was performed to incorporate intact and selective resection of ligaments, based on a novel force-dependent kinematics method, during gait (walking) and squatting. Deficiency of the PLC structures resulted in increased loading on the posterior cruciate ligament and anterior cruciate ligament. Among PLC structures, the PT is the most influential on cruciate ligament forces under dynamic loading conditions.
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Affiliation(s)
- Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | - Yong-Gon Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Republic of Korea
| | - Ji-Hoon Nam
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | | | - Sung-Jae Kim
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
- * E-mail:
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17
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Song Y, Xiong Y, Chen W, Zuo F, Tan L, Yao J, Chen N, Bleys R, Hu X, Zhang S, Wu Y. Sectional Anatomy and Three-Dimensional Visualization of the Posterolateral Complex of the Knee Joint Based on Undeformed High-Resolution Sectional Anatomical Images. Anat Rec (Hoboken) 2018; 301:1764-1773. [DOI: 10.1002/ar.23926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/30/2018] [Accepted: 03/05/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Yan Song
- Institute of Digital Medicine, Biomedical Engineering College; Third Military Medical University; Chongqing China
- Information Management Department; Third Military Medical University; Chongqing China
| | - Yan Xiong
- Department of Orthopedic, Daping Hospital; Third Military Medical University; Chongqing China
| | - Wei Chen
- Department of Radiology, Xinan Hospital; Third Military Medical University; Chongqing China
| | - Feng Zuo
- Information Management Department; Third Military Medical University; Chongqing China
| | - Liwen Tan
- Institute of Digital Medicine, Biomedical Engineering College; Third Military Medical University; Chongqing China
| | - Jie Yao
- Institute of Digital Medicine, Biomedical Engineering College; Third Military Medical University; Chongqing China
| | - Na Chen
- Institute of Digital Medicine, Biomedical Engineering College; Third Military Medical University; Chongqing China
| | - Ronald Bleys
- Department of Anatomy, Division of Surgical Specialties; University Medical Center Utrecht; Utrecht The Netherlands
| | - Xin Hu
- Institute of Digital Medicine, Biomedical Engineering College; Third Military Medical University; Chongqing China
| | - Shaoxiang Zhang
- Institute of Digital Medicine, Biomedical Engineering College; Third Military Medical University; Chongqing China
| | - Yi Wu
- Institute of Digital Medicine, Biomedical Engineering College; Third Military Medical University; Chongqing China
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18
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Filli L, Rosskopf AB, Sutter R, Fucentese SF, Pfirrmann CW. MRI Predictors of Posterolateral Corner Instability: A Decision Tree Analysis of Patients with Acute Anterior Cruciate Ligament Tear. Radiology 2018; 289:170-180. [DOI: 10.1148/radiol.2018180194] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Lukas Filli
- From the Departments of Radiology (L.F., A.B.R., R.S., C.W.A.P.) and Orthopedics (S.F.F.), Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland; and Faculty of Medicine, University of Zurich, Zurich, Switzerland (L.F., A.B.R., R.S., S.F.F., C.W.A.P.)
| | - Andrea B. Rosskopf
- From the Departments of Radiology (L.F., A.B.R., R.S., C.W.A.P.) and Orthopedics (S.F.F.), Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland; and Faculty of Medicine, University of Zurich, Zurich, Switzerland (L.F., A.B.R., R.S., S.F.F., C.W.A.P.)
| | - Reto Sutter
- From the Departments of Radiology (L.F., A.B.R., R.S., C.W.A.P.) and Orthopedics (S.F.F.), Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland; and Faculty of Medicine, University of Zurich, Zurich, Switzerland (L.F., A.B.R., R.S., S.F.F., C.W.A.P.)
| | - Sandro F. Fucentese
- From the Departments of Radiology (L.F., A.B.R., R.S., C.W.A.P.) and Orthopedics (S.F.F.), Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland; and Faculty of Medicine, University of Zurich, Zurich, Switzerland (L.F., A.B.R., R.S., S.F.F., C.W.A.P.)
| | - Christian W.A. Pfirrmann
- From the Departments of Radiology (L.F., A.B.R., R.S., C.W.A.P.) and Orthopedics (S.F.F.), Balgrist University Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland; and Faculty of Medicine, University of Zurich, Zurich, Switzerland (L.F., A.B.R., R.S., S.F.F., C.W.A.P.)
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19
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Beidokhti HN, Janssen D, van de Groes S, Verdonschot N. The peripheral soft tissues should not be ignored in the finite element models of the human knee joint. Med Biol Eng Comput 2018; 56:1189-1199. [PMID: 29214465 PMCID: PMC6013543 DOI: 10.1007/s11517-017-1757-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 11/20/2017] [Indexed: 01/14/2023]
Abstract
In finite element models of the either implanted or intact human knee joint, soft tissue structures like tendons and ligaments are being incorporated, but usually skin, peripheral knee soft tissues, and the posterior capsule are ignored and assumed to be of minor influence on knee joint biomechanics. It is, however, unknown how these peripheral structures influence the biomechanical response of the knee. In this study, the aim was to assess the significance of the peripheral soft tissues and posterior capsule on the kinematics and laxities of human knee joint, based on experimental tests on three human cadaveric specimens. Despite the high inter-subject variability of the results, it was demonstrated that the target tissues have a considerable influence on posterior translational and internal and valgus rotational laxities of lax knees under flexion. Consequently, ignoring these tissues from computational models may alter the knee joint biomechanics.
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Affiliation(s)
- Hamid Naghibi Beidokhti
- Orthopedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands.
| | - Dennis Janssen
- Orthopedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
| | | | - Nico Verdonschot
- Orthopedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
- Laboratory of Biomechanical Engineering, University of Twente, Enschede, The Netherlands
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20
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Nannaparaju M, Mortada S, Wiik A, Khan W, Alam M. Posterolateral corner injuries: Epidemiology, anatomy, biomechanics and diagnosis. Injury 2018; 49:1024-1031. [PMID: 29254623 DOI: 10.1016/j.injury.2017.10.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 09/03/2017] [Accepted: 10/07/2017] [Indexed: 02/02/2023]
Abstract
Increased internal and external rotational laxity of the knee may result from a wide range of pathologies in or around the knee. However, the principal cause of increased external rotational laxity is damage to the posterolateral corner (PLC). The aim of the review is to discuss the epidemiology, anatomy, biomechanics and diagnosis of PLC injuries.
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Affiliation(s)
| | - S Mortada
- Barking, Havering and Redbridge University Hospitals, Romford, UK
| | - A Wiik
- Barking, Havering and Redbridge University Hospitals, Romford, UK
| | - W Khan
- University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - M Alam
- Barking, Havering and Redbridge University Hospitals, Romford, UK
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Kang KT, Koh YG, Son J, Jung M, Oh S, Kim SJ, Kim SH. Biomechanical influence of deficient posterolateral corner structures on knee joint kinematics: A computational study. J Orthop Res 2018; 36:2202-2209. [PMID: 29436742 DOI: 10.1002/jor.23871] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 01/24/2018] [Indexed: 02/04/2023]
Abstract
The posterolateral corner (PLC) structures including the popliteofibular ligament (PFL), popliteus tendon (PT) and lateral collateral ligament (LCL) are important soft tissues for posterior translational, external rotational, and varus angulation knee joint instabilities. The purpose of this study was to determine the effects of deficient PLC structures on the kinematics of the knee joint under gait and squat loading conditions. We developed subject-specific computational models with full 12-degree-of-freedom tibiofemoral and patellofemoral joints for four male subjects and one female subject. The subject-specific knee joint models were validated with computationally predicted muscle activation, electromyography data, and experimental data from previous study. According to our results, deficiency of the PFL did not significantly influence knee joint kinematics compared to an intact model under gait loading conditions. Compared with an intact model under gait and squat loading conditions, deficiency of the PT led to significant increases in external rotation and posterior translation, while LCL deficiency increased varus angulation. Deficiency of all PLC structures led to the greatest increases in external rotation, varus angulation, and posterior translation. These results suggest that the PT is an important structure for external rotation and posterior translation, while the LCL is important for varus angulation under dynamic loading conditions. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-8, 2018.
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Affiliation(s)
- Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yong-Gon Koh
- Department of Orthopaedic Surgery, Joint Reconstruction Center, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, 06698, Republic of Korea
| | - Juhyun Son
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moonki Jung
- AnyBody Technology A/S, 10 Niels Jernes Vej, Aalborg, 9220, Denmark
| | - Sangyun Oh
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sung-Jae Kim
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sung-Hwan Kim
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
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22
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Harris MD, Cyr AJ, Ali AA, Fitzpatrick CK, Rullkoetter PJ, Maletsky LP, Shelburne KB. A Combined Experimental and Computational Approach to Subject-Specific Analysis of Knee Joint Laxity. J Biomech Eng 2017; 138:2529647. [PMID: 27306137 DOI: 10.1115/1.4033882] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Indexed: 01/14/2023]
Abstract
Modeling complex knee biomechanics is a continual challenge, which has resulted in many models of varying levels of quality, complexity, and validation. Beyond modeling healthy knees, accurately mimicking pathologic knee mechanics, such as after cruciate rupture or meniscectomy, is difficult. Experimental tests of knee laxity can provide important information about ligament engagement and overall contributions to knee stability for development of subject-specific models to accurately simulate knee motion and loading. Our objective was to provide combined experimental tests and finite-element (FE) models of natural knee laxity that are subject-specific, have one-to-one experiment to model calibration, simulate ligament engagement in agreement with literature, and are adaptable for a variety of biomechanical investigations (e.g., cartilage contact, ligament strain, in vivo kinematics). Calibration involved perturbing ligament stiffness, initial ligament strain, and attachment location until model-predicted kinematics and ligament engagement matched experimental reports. Errors between model-predicted and experimental kinematics averaged <2 deg during varus-valgus (VV) rotations, <6 deg during internal-external (IE) rotations, and <3 mm of translation during anterior-posterior (AP) displacements. Engagement of the individual ligaments agreed with literature descriptions. These results demonstrate the ability of our constraint models to be customized for multiple individuals and simultaneously call attention to the need to verify that ligament engagement is in good general agreement with literature. To facilitate further investigations of subject-specific or population based knee joint biomechanics, data collected during the experimental and modeling phases of this study are available for download by the research community.
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Smeets K, Slane J, Scheys L, Claes S, Bellemans J. Mechanical Analysis of Extra-Articular Knee Ligaments. Part One: Native knee ligaments. Knee 2017; 24:949-956. [PMID: 28784565 DOI: 10.1016/j.knee.2017.07.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/15/2017] [Accepted: 07/20/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to provide a characterization of the tensile properties of the medial collateral ligament (MCL), lateral collateral ligament (LCL), anterolateral ligament (ALL) and medial patellofemoral ligament (MPFL). Our hypothesis was that extra-articular knee ligaments are heterogeneous in nature and possess distinct material properties. METHODS MCL (n=12), LCL (n=11), MPFL (n=12) and ALL (n=19) samples from fresh frozen human cadaveric knees were subjected to uniaxial tensile testing to failure and analyzed for their material properties. The elastic modulus (slope of the linear portion of the stress/strain curve), ultimate stress (stress at failure), ultimate strain (strain at failure) and strain energy density (area under the stress/strain curve) were calculated. RESULTS The MCL had the highest elastic modulus (441.8±117.2MPa) and was significantly greater than the MPFL (294.6±190.4MPa) and LCL (289.0±159.7MPa) (P<0.05) as well as the ALL (173.7±91.8MPa) (P<0.001). The ultimate stress was significantly higher (P<0.05) for the LCL (83.6±38.1MPa) and MCL (72.4±20.7MPa), relative to the MPFL (49.1±31.0MPa) and ALL (46.4±20.1MPa). The ultimate strain of the LCL (41.0±9.9%) and ALL (37.8±7.9%) were significantly higher (P<0.05) compared to the MCL (22.9±2.5%) and MPFL (22.2±5.6%). The strain energy density of the LCL (15.2±6.4MPa) was significantly greater (P<0.05) than all other ligaments (ALL 7.8±3.1MPa, MCL 7.5±2.9MPa and MPFL 5.0±2.9MPa). CONCLUSIONS Extra-articular knee ligaments are a heterogeneous group with respect to material characteristics. Each ligament has tensile properties that are significantly different from others and treatment strategies should take these findings into account.
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Affiliation(s)
- Kristof Smeets
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium; Department of Orthopedic Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Joshua Slane
- Institute for Orthopaedic Research and Training, Division of Orthopaedics, University Hospitals Leuven/Department of Development and Regenartion, Faculty of Medicine, KULeuven, Leuven, Belgium
| | - Lennart Scheys
- Institute for Orthopaedic Research and Training, Division of Orthopaedics, University Hospitals Leuven/Department of Development and Regenartion, Faculty of Medicine, KULeuven, Leuven, Belgium
| | - Steven Claes
- Department of Orthopedic Surgery, AZ Herentals Hospital, Herentals, Belgium; Department of Orthopedic Surgery, University Hospitals Leuven, Pellenberg, Belgium
| | - Johan Bellemans
- Department of Orthopedic Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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Vap AR, Schon JM, Moatshe G, Cruz RS, Brady AW, Dornan GJ, Turnbull TL, LaPrade RF. The Role of the Peripheral Passive Rotation Stabilizers of the Knee With Intact Collateral and Cruciate Ligaments: A Biomechanical Study. Orthop J Sports Med 2017; 5:2325967117708190. [PMID: 28607939 PMCID: PMC5455885 DOI: 10.1177/2325967117708190] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND A subset of patients have clinical internal and/or external knee rotational instability despite no apparent injury to the cruciate or collateral ligaments. PURPOSE/HYPOTHESIS The purpose of this study was to assess the effect of sequentially cutting the posterolateral, anterolateral, posteromedial, and anteromedial structures of the knee on rotational stability in the setting of intact cruciate and collateral ligaments. It was hypothesized that cutting of the iliotibial band (ITB), anterolateral ligament and lateral capsule (ALL/LC), posterior oblique ligament (POL), and posteromedial capsule (PMC) would significantly increase internal rotation, while sectioning of the anteromedial capsule (AMC) and the popliteus tendon and popliteofibular ligament (PLT/PFL) would lead to a significant increase in external knee rotation. STUDY DESIGN Controlled laboratory study. METHODS Ten pairs (N = 20) of cadaveric knees were assigned to 2 sequential cutting groups (group 1: posterolateral-to-posteromedial [PL → PM] and group 2: posteromedial-to-posterolateral [PM → PL]). Specimens were subjected to applied 5-N·m internal and external rotation torques at knee flexion angles of 0°, 30°, 60°, and 90° while intact and after each cut state. Rotational changes were measured and compared with the intact and previous cut states. RESULTS Sectioning of the ITB significantly increased internal rotation at 60° and 90° by 5.4° and 6.2° in group 1 (PL → PM) and 3.5° and 3.8° in group 2 (PM → PL). PLT/PFL complex sectioning significantly increased external rotation at 60° and 90° by 2.7° and 2.9° in group 1 (PL → PM). At 60° and 90° in group 2 (PM → PL), ALL/LC sectioning produced significant increases in internal rotation of 3.1° and 3.5°, respectively. In group 2 (PM → PL), POL sectioning produced a significant increase in internal rotation of 2.0° at 0°. AMC sectioning significantly increased external rotation at 30° to 90° of flexion with a magnitude of change of <1° in both groups 1 (PL → PM) and 2 (PM → PL). CONCLUSION Collectively, the anterolateral corner structures provided primary internal rotation control of the knee from 60° to 90° of knee flexion in knees with intact cruciate and collateral ligaments. The ITB was the most significant primary stabilizer of internal rotation. The POL had a primary role for internal rotational stability at full extension. The PLT/PFL complex was a primary stabilizer for external rotation of the knee at 60° and 90°. CLINICAL RELEVANCE This study delineates the primary and secondary roles of the ITB, ALL/LC, POL, and PLT/PFL to rotatory stability of the knee and provides new information to understand knee rotational instabilities.
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Affiliation(s)
- Alexander R. Vap
- The Steadman Clinic, Vail, Colorado, USA
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Jason M. Schon
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, USA
- Orthopedic Department, Oslo University Hospital and University of Oslo, Oslo, Norway
- OSTRC, The Norwegian School of Sports Sciences, Oslo, Norway
| | | | - Alex W. Brady
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | | | - Robert F. LaPrade
- The Steadman Clinic, Vail, Colorado, USA
- Steadman Philippon Research Institute, Vail, Colorado, USA
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25
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Wu XD, Yu JH, Zou T, Wang W, LaPrade RF, Huang W, Sun SQ. Anatomical Characteristics and Biomechanical Properties of the Oblique Popliteal Ligament. Sci Rep 2017; 7:42698. [PMID: 28205540 PMCID: PMC5311875 DOI: 10.1038/srep42698] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 01/12/2017] [Indexed: 01/13/2023] Open
Abstract
This anatomical study sought to investigate the morphological characteristics and biomechanical properties of the oblique popliteal ligament (OPL). Embalmed cadaveric knees were used for the study. The OPL and its surrounding structures were dissected; its morphology was carefully observed, analyzed and measured; its biomechanical properties were investigated. The origins and insertions of the OPL were relatively similar, but its overall shape was variable. The OPL had two origins: one originated from the posterior surface of the posteromedial tibia condyle, merged with fibers from the semimembranosus tendon, the other originated from the posteromedial part of the capsule. The two origins converged and coursed superolaterally, then attached to the fabella or to the tendon of the lateral head of the gastrocnemius and blended with the posterolateral joint capsule. The OPL was classified into Band-shaped, Y-shaped, Z-shaped, Trident-shaped, and Complex-shaped configurations. The mean length, width, and thickness of the OPL were 39.54, 22.59, and 1.44 mm, respectively. When an external rotation torque (18 N·m) was applied both before and after the OPL was sectioned, external rotation increased by 8.4° (P = 0.0043) on average. The OPL was found to have a significant role in preventing excessive external rotation and hyperextension of the knee.
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Affiliation(s)
- Xiang-Dong Wu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- The First College of Clinical Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Jin-Hui Yu
- The First College of Clinical Medicine, Chongqing Medical University, Chongqing, 400016, China
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Tao Zou
- The First College of Clinical Medicine, Chongqing Medical University, Chongqing, 400016, China
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Wei Wang
- The First College of Clinical Medicine, Chongqing Medical University, Chongqing, 400016, China
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | | | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Shan-Quan Sun
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Human Gross Morphology Lab, National Class Preclinical Medicine Experimental Teaching Demonstration Center, Chongqing Medical University, Chongqing 400016, China
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Schweller EW, Ward PJ. Posterolateral Corner Knee Injuries: Review of Anatomy and Clinical Evaluation. J Osteopath Med 2015; 115:725-31. [DOI: 10.7556/jaoa.2015.148] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Abstract
The structures in the posterolateral corner of the knee, which stabilize the joint, are often involved in injuries to the posterior cruciate ligament. Familiar structures include the anterior cruciate ligament, posterior cruciate ligament, tibial collateral ligament, and menisci. Less familiar are the structures of the posterolateral corner, the most important of which are the fibular collateral ligament, popliteus tendon, and popliteofibular ligament, which resist varus angulation, external rotation, or posterior translation of the tibia. Injury to the posterolateral corner can be assessed with the posterolateral drawer, dial, reverse pivot shift, external rotation recurvatum, and varus stress tests. The purpose of this review is to highlight the posterolateral corner of the knee and injuries to its structures so that physicians can more accurately diagnose these injuries and provide appropriate treatment. Management focuses on restoring the fibular collateral ligament, popliteofibular ligament, and, in certain cases, the popliteus tendon.
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28
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Barba D, Barker L, Chhabra A. Anatomy and Biomechanics of the Posterior Cruciate Ligament and Posterolateral Corner. OPER TECHN SPORT MED 2015. [DOI: 10.1053/j.otsm.2015.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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29
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Malone WJ, Shruti A, Ko J, Salesky J. Magnetic Resonance Imaging of Posterior Cruciate and Posterolateral Corner Injuries of the Knee. OPER TECHN SPORT MED 2015. [DOI: 10.1053/j.otsm.2015.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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30
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Serbino Junior JW, Albuquerque RFDM, Pereira CAM, de Rezende MU, Lasmar RCP, Hernandez AJ. Posterolateral anatomical reconstruction restored varus but not rotational stability: A biomechanical study with cadavers. Knee 2015; 22:499-505. [PMID: 25899856 DOI: 10.1016/j.knee.2015.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 03/01/2015] [Accepted: 03/03/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIM Lesions to the posterolateral corner (PLC) of the knee are rarely isolated injuries, and they are potentially devastating, leading to progressive chondral injury, with important functional impairment. The objectives of this biomechanical study were to evaluate angular deformation with two loads and considering four flexion angles of the knee, varus and external rotation and in three situations of integrity, reconstruction and injury of posterolateral knee structures. METHODS The posterolateral structures of 10 cadaveric knees were submitted to three biomechanical assays: in the "intact condition", "injured", and "reconstructed". The technique used for the reconstruction was the one proposed by LaPrade et al., but with autografts of hamstring tendons instead. A device was designed to apply loads of 2 and 5Nm, with zero, 30°, 60° and 90° of knee flexion, in varus or in external rotation, measuring angular deformation with photogoniometry. RESULTS The anatomical reconstruction of the PLC proposed here did restore varus stability in all flexion angles (p<0.005), but not rotational stability. External rotation deformation at 90° was similar in all test conditions. In knee extension, external rotation was stabilized only at 2Nm. At 60°, external rotation was partially stabilized (p<0.05). CONCLUSIONS The anatomical PLC reconstruction using hamstring tendons restored varus but not external rotational stability. CLINICAL RELEVANCE The reconstruction of posterolateral corner injuries with autologous allografts is very important for regions were tissue banks are not available. This technique may be a first step to achieve this goal.
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Gallo RA, Sathyendra V, Sharkey NA, Lewis GS. Femoral fixation strength following soft-tissue posterolateral corner reconstruction using fibular-based technique: Biomechanical analysis of four techniques in normal and low-density synthetic bone. Knee 2015; 22:591-6. [PMID: 26233675 DOI: 10.1016/j.knee.2015.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/23/2015] [Accepted: 06/23/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Optimal femoral fixation of soft-tissue grafts has been described for anterior cruciate ligament reconstruction. Posterolateral corner reconstruction differs from ACL reconstruction in two ways: (a) soft-tissue fixation into the femur requires two tails and (b) the line of force is different. Our purpose was to determine the optimal femoral fixation of soft-tissue grafts during posterolateral corner reconstructions. We hypothesized that interference screw fixation is the strongest technique in normal-density lateral femoral condyle, whereas, cortically-based fixation techniques are stronger methods in low-density lateral femoral condyle. METHODS We evaluated elongation during cyclic loading, yield load, peak load-to-failure, and stiffness of four soft-tissue graft femoral fixation methods during posterolateral corner reconstruction. Our model included bovine flexor tendons and contoured synthetic bones. Grafts were secured to the lateral epicondyle in normal- or low-density bone models using spiked washer, button, interference screw, or button and interference screw. Five specimens for each were tested in each bone density. Analysis of variance using Tukey-Kramer adjustment for multiple hypothesis testing was used. Six cadaver bones whose density was analyzed using computerized tomography scan quantitation were tested using interference screw fixation. RESULTS No method produced significantly stronger yield load or peak load-to-failure in normal-density bone. In low-density bone, cortically-based methods produced significantly higher yield load or peak load-to-failure. Yield load or peak load-to-failure was significantly higher in normal-density bone when using spiked washer or interference screw fixation. CONCLUSION No femoral fixation method tested produced superior yield load or peak load-to-failure. Spiked washer and interference screw fixation are inferior fixation methods in low-density bone. CLINICAL RELEVANCE For fibular-based posterolateral corner reconstructions, all fixation methods tested are acceptable in high-density bone, while cortical fixation methods should be considered in low-density bone.
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Affiliation(s)
- Robert A Gallo
- Department of Orthopaedics and Rehabilitation, Penn State Hershey College of Medicine, Penn State Hershey Bone and Joint Institute, Hershey, PA, United States.
| | - Vikram Sathyendra
- Steel Valley Orthopedic Associates, P.C., Jefferson Hills, PA, United States
| | - Neil A Sharkey
- College of Health and Human Development, Pennsylvania State University, University Park, PA, United States
| | - Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Penn State Hershey College of Medicine, Penn State Hershey Bone and Joint Institute, Hershey, PA, United States
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Plaweski S, Belvisi B, Moreau-Gaudry A. Reconstruction of the Posterolateral Corner After Sequential Sectioning Restores Knee Kinematics. Orthop J Sports Med 2015; 3:2325967115570560. [PMID: 26535381 PMCID: PMC4555610 DOI: 10.1177/2325967115570560] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Various surgical techniques to treat posterolateral knee instability have been described. To date, the recommended treatment is an anatomic form of reconstruction in which the 3 key structures of the posterolateral corner (PLC) are addressed: the popliteofibular ligament, the popliteus tendon, and the lateral collateral ligament. Purpose/Hypothesis: The purpose of this study was to identify the role of each key structure of the PLC in kinematics of the knee and to biomechanically analyze a single-graft, fibular-based reconstruction that replicates the femoral insertions of the lateral collateral ligament and popliteus to repair the PLC. The hypothesis was that knee kinematics can be reasonably restored using a single graft with a 2-strand “modified Larson” technique. Study Design: Descriptive laboratory study. Methods: Eight fresh-frozen cadaveric knees were used in this study. We conducted sequential sectioning of the popliteofibular ligament (PFL) and then subsequently the popliteal tendon (PT), the lateral collateral ligament (LCL), and the anterior cruciate ligament (ACL). We then reconstructed the ACL first and then the posterolateral corner using the modified Larson technique. A surgical navigation system was used to measure varus laxity and external rotation at 0°, 30°, 60°, and 90° with a 9.8-N·m varus stress and 5-N·m external rotation force applied to the tibia. Results: In extension, varus laxity increased only after the sectioning of the lateral collateral ligament. At 30° of flexion, external rotation in varus and translation of the lateral tibial plateau increased after the isolated popliteofibular ligament section. From 60° to 90° of flexion, translation and mobility of the lateral plateau section increased after sectioning of the PFL. After reconstruction, we observed a restoration of external varus rotation in extension and translation of the lateral tibial plateau at 90° of flexion. This technique provided kinematics similar to the normal knee. Conclusion: The PFL has a key role between 30° and 90° of flexion, and the lateral collateral ligament plays a role in extension. Reconstruction with the modified Larson technique restores these 2 complementary stabilizers of the knee. Clinical Relevance: Although there are many different techniques to reconstruct the PLC-deficient knee, this study indicates that a single-graft, fibular-based reconstruction of the LCL and PT may restore varus and external rotation laxity to the knee.
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Affiliation(s)
- Stephane Plaweski
- Orthopaedic and Sports Traumatology Department, University of Grenoble, CHU Grenoble South Hospital, Grenoble, France
| | - Baptiste Belvisi
- Orthopaedic and Sports Traumatology Department, University of Grenoble, CHU Grenoble South Hospital, Grenoble, France
| | - Alexandre Moreau-Gaudry
- Laboratoire TIMC-IMAG-Equipe GMCAO. Institut d'Ingénierie et de l'Information de Santé, La Tronche Cedex, France
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The popliteal fibular ligament in acute knee trauma: patterns of injury on MR imaging. Skeletal Radiol 2015; 44:1413-9. [PMID: 26025122 DOI: 10.1007/s00256-015-2176-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 05/05/2015] [Accepted: 05/21/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the patterns of injury associated with injury to the popliteofibular ligament injury. MATERIALS AND METHODS A retrospective review was performed of 180 MRI scans undertaken for acute knee trauma. Scans were excluded if the time of injury was over 4 weeks from the time of the scan, or if there was a history of septic arthritis, inflammatory arthropathy, previous knee surgery, or significant artefact. An agreed criterion for assessing the structures of the posterolateral ligamentous complex was defined and in each scan, the popliteofibular ligament (PFL) was scored as normal or injured. The menisci, ligaments, and tendons of each knee were also assessed. RESULTS The mean age was 25.7 years (range, 9-65 years) and 72.2% (n = 130) patients were male. The PFL was injured in 36 cases (20%). There is a significant association between PFL injury and ACL rupture (p = 0.0001), ITB injury (p = 0.0001), PCL injury (p = 0.0373), in addition to associations with injury to other posterolateral corner structures including the lateral collateral ligament (p = 0.0001), biceps femoris tendon (p = 0.0014), and popliteus tendon (p = 0.0014). Of our series of PFL injuries, nine cases (25%) were associated with further injuries of posterolateral corner structures and in 27 cases (75%) the PFL was the only posterolateral corner structure torn. CONCLUSIONS PFL injury is not uncommon in acute knee trauma and is associated with significant internal derangement of the knee, especially anterior cruciate ligament rupture, ITB sprain, and injury to other structures within the posterolateral corner.
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Takeda S, Tajima G, Fujino K, Yan J, Kamei Y, Maruyama M, Kikuchi S, Doita M. Morphology of the femoral insertion of the lateral collateral ligament and popliteus tendon. Knee Surg Sports Traumatol Arthrosc 2015; 23:3049-54. [PMID: 24839040 DOI: 10.1007/s00167-014-3059-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 05/02/2014] [Indexed: 01/13/2023]
Abstract
PURPOSE To clarify the femoral insertion of the lateral collateral ligament (LCL) and popliteus tendon (PT) and related osseous landmarks on three-dimensional images. METHODS Twenty-six non-paired, formalin-fixed human cadaveric knees were evaluated in this study. Femoral insertion of the LCL and PT was identified and marked. Three-dimensional images were created, and the surface area, location, positional relationships, and morphology of the femoral insertion of the LCL, PT, and related osseous structures were analysed. RESULTS The mean surface areas of the LCL and PT femoral insertions were 55.8 ± 25.0 and 52.5 ± 24.2 mm(2), respectively. Variations in the positional relationships between the LCL and PT insertions (PT inserted parallel and posterior to the LCL insertion to the long axis of the femur) were observed. The lateral epicondyle and popliteal sulcus could be clearly identified as osseous landmarks on three-dimensional images in all knees. Most of the LCL was inserted postero-distal to the apex of the lateral epicondyle, and the PT was inserted at the anterior end of the popliteal sulcus in all knees. CONCLUSION We observed variation in the positional relationship between the femoral insertion of the LCL and PT. However, the relationships between their insertions and osseous landmarks were consistent. The findings of this study contribute to the understanding of the PLC osseous anatomy and should assist surgeons in performing PLC surgery with a more anatomic perspective.
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Affiliation(s)
- Sanjuro Takeda
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Goro Tajima
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan.
| | - Kotaro Fujino
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Jun Yan
- Department of Anatomy, Iwate Medical University, Morioka, Japan
| | - Youichi Kamei
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Moritaka Maruyama
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Shuhei Kikuchi
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Minoru Doita
- Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
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Lenhart RL, Kaiser J, Smith CR, Thelen DG. Prediction and Validation of Load-Dependent Behavior of the Tibiofemoral and Patellofemoral Joints During Movement. Ann Biomed Eng 2015; 43:2675-85. [PMID: 25917122 DOI: 10.1007/s10439-015-1326-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/16/2015] [Indexed: 01/05/2023]
Abstract
The study objective was to construct and validate a subject-specific knee model that can simulate full six degree of freedom tibiofemoral and patellofemoral joint behavior in the context of full body movement. Segmented MR images were used to reconstruct the geometry of 14 ligament bundles and articular cartilage surfaces. The knee was incorporated into a lower extremity musculoskeletal model, which was then used to simulate laxity tests, passive knee flexion, active knee flexion, and human walking. Simulated passive and active knee kinematics were shown to be consistent with subject-specific measures obtained via dynamic MRI. Anterior tibial translation and internal tibial rotation exhibited the greatest variability when uncertainties in ligament properties were considered. When used to simulate walking, the model predicted knee kinematic patterns that differed substantially from passive joint behavior. Predictions of ean knee cartilage contact pressures during normal gait reached 6.2 and 2.8 Pa on the medial tibial plateau and patellar facets, respectively. Thus, the dynamic modeling framework can be used to simulate the interaction of soft tissue loads and cartilage contact during locomotion activities, and therefore provides a basis to simulate the effects of soft tissue injury and surgical treatment on functional knee mechanics.
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Affiliation(s)
- Rachel L Lenhart
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Jarred Kaiser
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Colin R Smith
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Darryl G Thelen
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA. .,Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA. .,Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI, USA.
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36
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Fibular Head and Tibial-based (2-Tailed) Posterolateral Corner Reconstruction. Sports Med Arthrosc Rev 2015; 23:44-50. [DOI: 10.1097/jsa.0000000000000041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Sheehan SE, Khurana B, Gaviola G, Davis KW. A biomechanical approach to interpreting magnetic resonance imaging of knee injuries. Magn Reson Imaging Clin N Am 2014; 22:621-48. [PMID: 25442026 DOI: 10.1016/j.mric.2014.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This article discusses common injury mechanisms and the subsequent constellation of magnetic resonance (MR) imaging findings in the knee following trauma in the context of instability, as distinguished by the degree of knee flexion and tibial rotation at the time of initial injury, in addition to the direction and magnitude of the responsible force vectors. Using 3-dimensional imaging, common injury mechanisms are illustrated and correlated with MR imaging findings of the resulting osteochondral, ligamentous, meniscal, and musculotendinous lesions. The most common classification and grading systems for these individual lesions and their subsequent treatment implications are discussed.
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Affiliation(s)
- Scott E Sheehan
- Department of Musculoskeletal Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Bharti Khurana
- Department of Emergency Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Glenn Gaviola
- Department of Musculoskeletal Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Kirkland W Davis
- Department of Musculoskeletal Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA
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Helito CP, Bonadio MB, Demange MK, da Mota e Albuquerque RF, Pécora JR, Camanho GL, Angelini FJ. Functional assessment of combined reconstruction of the anterior cruciate ligament and posterolateral corner with a single femoral tunnel: a two-year minimum follow-up. INTERNATIONAL ORTHOPAEDICS 2014; 39:543-8. [PMID: 25376657 DOI: 10.1007/s00264-014-2576-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 10/20/2014] [Indexed: 01/14/2023]
Abstract
PURPOSE A technique for combined reconstruction of the anterior cruciate ligament (ACL) and posterolateral corner (PLC) with a single femoral tunnel was recently described. This technique aims to avoid tunnel confluence in the lateral femoral condyle. Because there have been no studies on the functional outcomes and possible complications of this technique, our goal is to demonstrate a two-year minimum follow-up of patients who underwent this type of reconstruction. METHODS Nine patients were prospectively evaluated. The ACL was reconstructed with an anatomic single bundle, and the PLC structures reconstructed were the lateral collateral ligament, the popliteus tendon, and the popliteofibular ligament. Patients were evaluated using the objective and subjective International Knee Documentation Committee (IKDC) and the Lysholm and Tegner scales before and after the surgical procedure. RESULTS The mean follow-up period of the studied patients was 27.3 months. The mean subjective IKDC score rose from 43.6 to 84.0, and the Lysholm score rose from 62.1 to 90.8. In the final assessment, six patients were classified as IKDC A and three as IKDC B. According to the Tegner scale, five patients were able to return to their level of activity prior to the injury. There were no reconstruction failures. One patient experienced postoperative infection and pain in the lateral scar. CONCLUSIONS The results of the reconstruction of ACL injuries associated with PLC with a single femoral tunnel produced a good functional outcome and a low incidence of complications.
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Affiliation(s)
- Camilo Partezani Helito
- Department of Orthopaedics and Traumatology, Faculty of Medicine, University of São Paulo, 05403-010, São Paulo, Brazil,
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Geiger D, Chang EY, Pathria MN, Chung CB. Posterolateral and Posteromedial Corner Injuries of the Knee. Magn Reson Imaging Clin N Am 2014; 22:581-99. [PMID: 25442024 DOI: 10.1016/j.mric.2014.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Daniel Geiger
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, Rome 00161, Italy
| | - Eric Y Chang
- VA Healthcare San Diego, 3350 La Jolla Village Drive, La Jolla, CA 92161, USA; Department of Radiology, University of California-San Diego, 408 Dickinson Street, San Diego, CA 92103-8226, USA
| | - Mini N Pathria
- Department of Radiology, University of California-San Diego, 408 Dickinson Street, San Diego, CA 92103-8226, USA
| | - Christine B Chung
- VA Healthcare San Diego, 3350 La Jolla Village Drive, La Jolla, CA 92161, USA; Department of Radiology, University of California-San Diego, 408 Dickinson Street, San Diego, CA 92103-8226, USA.
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Successful nonoperative treatment of isolated popliteus tendon avulsion fractures in two adolescents. Case Rep Orthop 2014; 2014:759419. [PMID: 25197598 PMCID: PMC4150439 DOI: 10.1155/2014/759419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/23/2014] [Indexed: 11/18/2022] Open
Abstract
Isolated popliteal tendon avulsion fractures are relatively uncommon in the pediatric population as other posterolateral lateral structures are often involved. This report describes two skeletally immature male patients who presented with knee injuries without ligamentous instability and were subsequently diagnosed with isolated popliteus tendon avulsion fractures. Both of these patients were managed nonoperatively and had subjectively full recoveries. As the treatment for isolated popliteal tendon avulsion fractures is still unclear, the report here may contribute to strategies regarding conservative treatment of these injuries.
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Song YB, Watanabe K, Hogan E, D'Antoni AV, Dilandro AC, Apaydin N, Loukas M, Shoja MM, Tubbs RS. The fibular collateral ligament of the knee: a detailed review. Clin Anat 2014; 27:789-97. [PMID: 24948572 DOI: 10.1002/ca.22301] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 05/03/2013] [Accepted: 06/26/2013] [Indexed: 01/13/2023]
Abstract
The fibular collateral ligament (FCL) is one of the larger ligaments of the knee. The FCL, along with the popliteus tendon, arcuate popliteal ligament, and joint capsule, make up the posterolateral corner of the knee. Recently, there has there been an increased awareness and research on the structures of the posterolateral corner of the knee, particularly the FCL. Studying the detailed structure of the FCL may provide a better understanding that can lead to better diagnosis and treatments following injury. Therefore, this article reviews the FCL, which appears to be the primary restraint to varus rotation but is poorly oriented to resist external rotation of the knee.
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Affiliation(s)
- Young-Bin Song
- Pediatric Neurosurgery Children's of Alabama, Birmingham, AL
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Jadhav SP, More SR, Riascos RF, Lemos DF, Swischuk LE. Comprehensive Review of the Anatomy, Function, and Imaging of the Popliteus and Associated Pathologic Conditions. Radiographics 2014; 34:496-513. [DOI: 10.1148/rg.342125082] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Selective lateral muscle activation in moderate medial knee osteoarthritis subjects does not unload medial knee condyle. J Biomech 2014; 47:1409-15. [PMID: 24581816 DOI: 10.1016/j.jbiomech.2014.01.038] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 12/11/2013] [Accepted: 01/20/2014] [Indexed: 11/23/2022]
Abstract
There is some debate in the literature regarding the role of quadriceps-hamstrings co-contraction in the onset and progression of knee osteoarthritis. Does co-contraction during walking increase knee contact loads, thereby causing knee osteoarthritis, or might it be a compensatory mechanism to unload the medial tibial condyle? We used a detailed musculoskeletal model of the lower limb to test the hypothesis that selective activation of lateral hamstrings and quadriceps, in conjunction with inhibited medial gastrocnemius, can actually reduce the joint contact force on the medial compartment of the knee, independent of changes in kinematics or external forces. "Baseline" joint loads were computed for eight subjects with moderate medial knee osteoarthritis (OA) during level walking, using static optimization to resolve the system of muscle forces for each subject's scaled model. Holding all external loads and kinematics constant, each subject's model was then perturbed to represent non-optimal "OA-type" activation based on mean differences detected between electromyograms (EMG) of control and osteoarthritis subjects. Knee joint contact forces were greater for the "OA-type" than the "Baseline" distribution of muscle forces, particularly during early stance. The early-stance increase in medial contact load due to the "OA-type" perturbation could implicate this selective activation strategy as a cause of knee osteoarthritis. However, the largest increase in the contact load was found at the lateral condyle, and the "OA-type" lateral activation strategy did not increase the overall (greater of the first or second) medial peak contact load. While "OA-type" selective activation of lateral muscles does not appear to reduce the medial knee contact load, it could allow subjects to increase knee joint stiffness without any further increase to the peak medial contact load.
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MRI of knee ligament injury and reconstruction. J Magn Reson Imaging 2013; 38:757-73. [DOI: 10.1002/jmri.24311] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 06/19/2013] [Indexed: 01/07/2023] Open
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Yang BS, Bae WH, Ha JK, Lee DW, Jang HW, Kim JG. Posterolateral corner reconstruction using the single fibular sling method for posterolateral rotatory instability of the knee. Am J Sports Med 2013; 41:1605-12. [PMID: 23720444 DOI: 10.1177/0363546513488866] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recently, posterolateral corner (PLC) reconstruction techniques have been developed based on an anatomic study of cadaveric dissections. However, the best operative method for various anatomic reconstructions remains controversial. HYPOTHESIS The anatomic single fibular sling method for PLC reconstruction would be sufficiently strong to control posterolateral rotatory instability without an additional tibial sling. STUDY DESIGN Case series; Level of evidence, 4. METHODS This retrospective cohort study analyzed 60 knees in 60 patients who underwent anatomic PLC reconstruction using the single fibular sling method with a tibialis anterior allograft, with a minimum follow-up period of 2 years. Ninety percent of the patients had concomitant reconstruction of one or both cruciate ligaments. Preoperative and postoperative dial test, varus stress test, and subjective clinical outcomes including Lysholm score, International Knee Documentation Committee (IKDC) subjective scores, and stress radiographs, including varus and posterior stress, were compared. In addition, intraoperative arthroscopic findings were analyzed. RESULTS The mean length of clinical follow-up was 35.6 months (range, 24-65 months). Forty-two (70%) patients showed no rotational instability postoperatively. Varus laxity improved, with 96.7% of the patients assessed as grade 0 or 1. The mean side-to-side difference in varus stress test was reduced from 2.32 ± 1.33 mm preoperatively to 0.37 ± 1.48 mm postoperatively. Posterior stress radiography in combined posterior cruciate ligament reconstruction showed a mean posterior tibial translation of 14.7 ± 2.83 mm preoperatively and 4.06 ± 1.40 mm at final follow-up. The Lysholm and IKDC subjective scores improved from 52 ± 6.7 to 87.7 ± 12.3 and from 44.8 ± 6.3 to 77.6 ± 14.2 (P < .001), respectively. There were no significant differences in clinical outcome or varus laxity between isolated PLC and combined injuries. CONCLUSION Anatomic PLC reconstruction using a single fibular sling method is an effective and relatively simple procedure for most patients with posterolateral rotatory instability, with the exception of those with severe multiple injuries.
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Affiliation(s)
- Byoung Se Yang
- Department of Orthopedic Surgery, Bundang Chuk Hospital, Gyeonggi-do, Korea
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Kim YH, Purevsuren T, Kim K, Oh KJ. Contribution of posterolateral corner structures to knee joint translational and rotational stabilities: a computational study. Proc Inst Mech Eng H 2013; 227:968-75. [PMID: 23736993 DOI: 10.1177/0954411913490456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
It has been reported that posterolateral corner structures, including the lateral collateral ligament, the popliteus tendon, and the popliteofibular ligament, may play important roles in reducing external rotational and posterior translational instabilities. However, there are few studies focusing on the quantitative influence of posterolateral corner structures on knee joint stability, due to the difficulty of controlling experimental conditions. In this study, a knee model that included posterolateral corner structures was developed. It was validated by comparison to previous experimental studies using the posterior drawer test, dial test, and varus stress test. The posterior translation, external rotation, and varus rotation were then predicted in order to investigate the contribution of posterolateral corner structures to translational and rotational stabilities. Our results indicate that posterolateral corner structures, including the popliteofibular ligament and the popliteus tendon, could contribute to posterior translational and external rotational stabilities, as clinical observations had suggested. Therefore, the addition of posterolateral corner structures to knee joint models may improve the utility of such models.
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Affiliation(s)
- Yoon Hyuk Kim
- Department of Mechanical Engineering, Kyung Hee University, Yongin, Korea.
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Ibrahim SAR, Ghafar S, Salah M, Abo Alnas M, Al Misfer A, Farouk H, Al Haran H, Khirait S. Surgical management of traumatic knee dislocation with posterolateral corner injury. Arthroscopy 2013; 29:733-41. [PMID: 23395116 DOI: 10.1016/j.arthro.2012.11.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 11/17/2012] [Accepted: 11/20/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the results of our method of surgical treatment of traumatic knee dislocation with injury to the posterolateral corner by use of a standardized protocol. METHODS Twenty-five consecutive patients presented with a grossly dislocated or reduced knee. Five of these patients were not included in this series. The remaining 20 patients were treated by primary arthroscopic reconstruction. The anterior cruciate ligament (ACL) was reconstructed using gracilis tendon reinforced with artificial ligament (Ligament Augmentation and Reconstruction System [LARS] ligament); the posterior cruciate ligament (PCL) was reconstructed with semitendinosus tendon and reinforced with LARS ligament; and the posterolateral corner was treated using the gracilis and semitendinosus tendons from the uninjured knee. Twenty patients returned for subjective and objective evaluation at a minimum of 24 months after surgery. Early mobilization through continuous and active exercise was started on the fourth day postoperatively. RESULTS At a mean follow-up of 44 months, the mean Lysholm score was 90 points, the mean score on the survey of daily activities was 90 points, and the sports activities score on the knee outcome survey averaged 80 points. By the rating of Meyers et al. the results were excellent in 6 patients, good in 10 patients, fair in 3 patients, and poor in one patient. The final International Knee Documentation Committee (IKDC) rating was not normal in any knee. The mean loss of extension was 2° (range, 0° to 3°) and loss of flexion was 12° (range, 10° to 15°). CONCLUSIONS By using the described method of arthroscopically assisted reconstruction of the cruciate ligaments and the posterolateral corner, 80% of the patients had good subjective results and functional stability, and according to the IKDC scale, 45% of knees were nearly normal, 45% were abnormal, and 10% were severely abnormal. No patient's rating returned to normal. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Samir Abdul Razik Ibrahim
- Al Razi Orthopaedic Hospital, Sports Medical Centre, Clinical Tutor Medical School, Kuwait University, Kuwait.
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Geiger D, Chang E, Pathria M, Chung CB. Posterolateral and posteromedial corner injuries of the knee. Radiol Clin North Am 2013; 51:413-32. [PMID: 23622092 DOI: 10.1016/j.rcl.2012.10.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Posterolateral (PLC) and posteromedial (PMC) corners of the knee represent complex anatomic regions because of intricate soft tissue and osseous relationships in small areas. Concise knowledge of these relationships is necessary before approaching their evaluation at imaging. Magnetic resonance imaging offers an accurate imaging diagnostic tool to establish normal anatomy and diagnose and characterize soft tissue and osseous injury. It is important to carefully evaluate the PLC and PMC structures on magnetic resonance imaging before planned surgical intervention to avoid potential complications resulting from occult injury.
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Affiliation(s)
- Daniel Geiger
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome 00161, Italy
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A review of the anatomical, biomechanical and kinematic findings of posterior cruciate ligament injury with respect to non-operative management. Knee 2012; 19:738-45. [PMID: 23022245 DOI: 10.1016/j.knee.2012.09.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 08/14/2012] [Accepted: 09/03/2012] [Indexed: 02/02/2023]
Abstract
An understanding of the kinematics of posterior cruciate ligament (PCL) deficiency is important for the diagnosis and management of patients with isolated PCL injury. The kinematics of PCL injury has been analysed through cadaveric and in vivo imaging studies. Cadaveric studies have detailed the anatomy of the PCL. It consists of two functional bundles, anterolateral and posteromedial, which exhibit different tensioning patterns through the arc of knee flexion. Isolated sectioning of the PCL and its related structures in cadaveric specimens has defined its primary and secondary restraining functions. The PCL is the primary restraint to posterior tibia translation above 30° and is a secondary restraint below 30° of knee flexion. Furthermore, sectioning of the PCL produces increased chondral deformation forces in the medial compartment as the knee flexes. However, the drawback of cadaveric studies is that they can not replicate the contribution of surrounding neuromuscular structures to joint stability that occurs in the clinical setting. To address this, there have been in vivo studies that have examined the kinematics of the PCL deficient knee using imaging modalities whilst subjects perform dynamic manoeuvres. These studies demonstrate significant posterior subluxation of the medial tibia as the knee flexes. The results of these experimental studies are in line with clinical consequences of PCL deficiency. In particular, arthroscopic evaluation of subjects with isolated PCL injuries demonstrate an increased incidence of chondral lesions in the medial compartment. Yet despite the altered kinematics with PCL injury only a minority of patients require surgery for persistent instability and the majority of athletes are able to return to sport following a period of non-operative rehabilitation. Specifically, non-operative management centres on a programme of quadriceps strengthening and hamstring inhibition to minimise posterior tibial load. The mechanism behind the neuromuscular adaptation that allows the majority of athletes to return to sport has been investigated but not clearly elucidated. The purpose of this review paper is to draw together the findings of experimental studies on the anatomical and kinematic effects of PCL injury and summarise their relevance with respect to non-operative management and functional outcome in patients with isolated PCL deficiency.
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Lim HC, Bae JH, Bae TS, Moon BC, Shyam AK, Wang JH. Relative role changing of lateral collateral ligament on the posterolateral rotatory instability according to the knee flexion angles: a biomechanical comparative study of role of lateral collateral ligament and popliteofibular ligament. Arch Orthop Trauma Surg 2012; 132:1631-6. [PMID: 22847725 DOI: 10.1007/s00402-012-1591-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Indexed: 11/27/2022]
Abstract
PURPOSE This cadaveric study assessed the relative role of the lateral collateral ligament (LCL) and popliteofibular ligament (PFL) in limiting tibia external rotation. METHODS Eight paired cadaveric knees were divided into two groups. The specimens were mounted on a rotational wheel and 5 Nm external rotation torque was applied before and after cutting the ligaments at 0°-30°-60°-90° knee flexion. Three cutting steps were applied: (1) PT (popliteus tendon)-, (2) LCL-, (3) PFL in group I, and (1) PT-, (2) PFL-, (3)LCL in group II. Increased external rotation at each step was taken as the ratio of final external rotation at the end of step 3. Repeated measure ANOVA and a Mann-Whitney U test were used for statistical analysis. RESULTS At step 2, the ratio of increased external rotation after cutting the LCL (group I) was similar to the ratio after cutting the PFL (group II) at 0° and 30° flexion, but that of group I was lower than group II at 60° and 90° flexion (p = 0.029 and p = 0.029). At step-3, the ratio after cutting the LCL (group II) was less than the ratio after cutting the PFL (group I) at 90° flexion (p = 0.029). CONCLUSION The PFL and LCL play equally important roles in limiting external rotation at the knee extended position (0°, 30°) but the LCL contribution becomes smaller than PFL at the flexed position (60°, 90°).
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Affiliation(s)
- Hong Chul Lim
- Department of Orthopaedic Surgery, Korea University School of Medicine, Guro Hospital, Seoul, South Korea
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