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Oehme S, Moewis P, Boeth H, Bartek B, von Tycowicz C, Ehrig R, Duda GN, Jung T. Altered knee kinematics after posterior cruciate ligament single-bundle reconstruction-a comprehensive prospective biomechanical in vivo analysis. Front Bioeng Biotechnol 2024; 12:1322136. [PMID: 38352697 PMCID: PMC10863728 DOI: 10.3389/fbioe.2024.1322136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/16/2024] [Indexed: 02/16/2024] Open
Abstract
Purpose: Passive tibiofemoral anterior-posterior (AP) laxity has been extensively investigated after posterior cruciate ligament (PCL) single-bundle reconstruction. However, the PCL also plays an important role in providing rotational stability in the knee. Little is known in relation to the effects of PCL single-bundle reconstruction on passive tibiofemoral rotational laxity. Gait biomechanics after PCL reconstruction are even less understood. The aim of this study was a comprehensive prospective biomechanical in vivo analysis of the effect of PCL single-bundle reconstruction on passive tibiofemoral rotational laxity, passive anterior-posterior laxity, and gait pattern. Methods: Eight patients undergoing PCL single-bundle reconstruction (seven male, one female, mean age 35.6 ± 6.6 years, BMI 28.0 ± 3.6 kg/m2) were analyzed preoperatively and 6 months postoperatively. Three of the eight patients received additional posterolateral corner (PLC) reconstruction. Conventional stress radiography was used to evaluate passive translational tibiofemoral laxity. A previously established rotometer device with a C-arm fluoroscope was used to assess passive tibiofemoral rotational laxity. Functional gait analysis was used to examine knee kinematics during level walking. Results: The mean side-to-side difference (SSD) in passive posterior translation was significantly reduced postoperatively (12.1 ± 4.4 mm vs. 4.3 ± 1.8 mm; p < 0.01). A significant reduction in passive tibiofemoral rotational laxity at 90° knee flexion was observed postoperatively (27.8° ± 7.0° vs. 19.9° ± 7.5°; p = 0.02). The range of AP tibiofemoral motion during level walking was significantly reduced in the reconstructed knees when compared to the contralateral knees at 6-month follow-up (16.6 ± 2.4 mm vs. 13.5 ± 1.6 mm; p < 0.01). Conclusion: PCL single-bundle reconstruction with optional PLC reconstruction reduces increased passive tibiofemoral translational and rotational laxity in PCL insufficient knees. However, increased passive tibiofemoral translational laxity could not be fully restored and patients showed altered knee kinematics with a significantly reduced range of tibiofemoral AP translation during level walking at 6-month follow-up. The findings of this study indicate a remaining lack of restoration of biomechanics after PCL single-bundle reconstruction in the active and passive state, which could be a possible cause for joint degeneration after PCL single-bundle reconstruction.
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Affiliation(s)
- Stephan Oehme
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Philippe Moewis
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Julius Wolff Institute Berlin, Berlin, Germany
| | - Heide Boeth
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Julius Wolff Institute Berlin, Berlin, Germany
| | - Benjamin Bartek
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | | | - Rainald Ehrig
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Julius Wolff Institute Berlin, Berlin, Germany
- Zuse Institute Berlin, Berlin, Germany
| | - Georg N. Duda
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Julius Wolff Institute Berlin, Berlin, Germany
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Berlin, Germany
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PCL insufficient patients with increased translational and rotational passive knee joint laxity have no increased range of anterior-posterior and rotational tibiofemoral motion during level walking. Sci Rep 2022; 12:13232. [PMID: 35918487 PMCID: PMC9345965 DOI: 10.1038/s41598-022-17328-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
Passive translational tibiofemoral laxity has been extensively examined in posterior cruciate ligament (PCL) insufficient patients and belongs to the standard clinical assessment. However, objective measurements of passive rotational knee laxity, as well as range of tibiofemoral motion during active movements, are both not well understood. None of these are currently quantified in clinical evaluations of patients with PCL insufficiency. The objective of this study was to quantify passive translational and rotational knee laxity as well as range of anterior–posterior and rotational tibiofemoral motion during level walking in a PCL insufficient patient cohort as a basis for any later clinical evaluation and therapy. The laxity of 9 patient knees with isolated PCL insufficiency or additionally posterolateral corner (PLC) insufficiency (8 males, 1 female, age 36.78 ± 7.46 years) were analysed and compared to the contralateral (CL) knees. A rotometer device with a C-arm fluoroscope was used to assess the passive tibiofemoral rotational laxity while stress radiography was used to evaluate passive translational tibiofemoral laxity. Functional gait analysis was used to examine the range of anterior–posterior and rotational tibiofemoral motion during level walking. Passive translational laxity was significantly increased in PCL insufficient knees in comparison to the CL sides (15.5 ± 5.9 mm vs. 3.7 ± 1.9 mm, p < 0.01). Also, passive rotational laxity was significantly higher compared to the CL knees (26.1 ± 8.2° vs. 20.6 ± 5.6° at 90° knee flexion, p < 0.01; 19.0 ± 6.9° vs. 15.5 ± 5.9° at 60° knee flexion, p = 0.04). No significant differences were observed for the rotational (16.3 ± 3.7° vs. 15.2 ± 3.6°, p = 0.43) and translational (17.0 ± 5.4 mm vs. 16.1 ± 2.8 mm, p = 0.55) range of anterior–posterior and rotational tibiofemoral motion during level walking conditions for PCL insufficient knees compared to CL knees respectively. The present study illustrates that patients with PCL insufficiency show a substantial increased passive tibiofemoral laxity, not only in tibiofemoral translation but also in tibiofemoral rotation. Our data indicate that this increased passive multiplanar knee joint laxity can be widely compensated during level walking. Further studies should investigate progressive changes in knee joint laxity and kinematics post PCL injury and reconstruction to judge the individual need for therapy and effects of physiotherapy such as quadriceps force training on gait patterns in PCL insufficient patients.
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Winkler PW, Zsidai B, Wagala NN, Hughes JD, Horvath A, Senorski EH, Samuelsson K, Musahl V. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics. Knee Surg Sports Traumatol Arthrosc 2021; 29:672-681. [PMID: 33201271 PMCID: PMC7917041 DOI: 10.1007/s00167-020-06357-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/26/2020] [Indexed: 01/10/2023]
Abstract
The posterior cruciate ligament (PCL) represents an intra-articular structure composed of two distinct bundles. Considering the anterior and posterior meniscofemoral ligaments, a total of four ligamentous fibre bundles of the posterior knee complex act synergistically to restrain posterior and rotatory tibial loads. Injury mechanisms associated with high-energy trauma and accompanying injury patterns may complicate the diagnostic evaluation and accuracy. Therefore, a thorough and systematic diagnostic workup is necessary to assess the severity of the PCL injury and to initiate an appropriate treatment approach. Since structural damage to the PCL occurs in more than one third of trauma patients experiencing acute knee injury with hemarthrosis, background knowledge for management of PCL injuries is important. In Part 1 of the evidence-based update on management of primary and recurrent PCL injuries, the anatomical, biomechanical, and diagnostic principles are presented. This paper aims to convey the anatomical and biomechanical knowledge needed for accurate diagnosis to facilitate subsequent decision-making in the treatment of PCL injuries.Level of evidence V.
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Affiliation(s)
- Philipp W. Winkler
- Department for Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany ,Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Bálint Zsidai
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Nyaluma N. Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Jonathan D. Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
| | - Alexandra Horvath
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden ,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St, Pittsburgh, PA 15203 USA
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Anatomy and Biomechanics of the Posterior Cruciate Ligament and Their Surgical Implications. Sports Med Arthrosc Rev 2020; 28:e1-e10. [PMID: 31895324 DOI: 10.1097/jsa.0000000000000267] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Knowledge and understanding of the complex anatomy and biomechanical function of the native posterior cruciate ligament (PCL) is vitally important when evaluating PCL injury and possible reconstruction. The PCL has important relationships with the anterior cruciate ligament, menisci, tibial spines, ligament of Humphrey, ligament of Wrisberg, and the posterior neurovascular structures. Through various experimental designs, the biomechanical role of the PCL has been elucidated. The PCL has its most well-defined role as a primary restraint/stabilizer to posterior stress and it seems this role is greatest at higher degrees of knee flexion. The natural history of high-grade deficiency leads to increased contact pressures and degeneration of both the medial and patellofemoral compartments. There is still considerable debate regarding whether high-level athletes can return to sport at the same level with conservative treatment of a high-grade PCL tear, and whether greater laxity in the knee correlates with decreased subjective and objective outcomes. Poor surgical outcomes after PCL reconstruction have been attributed to many factors, the most common of which include: additional intra-articular pathology, poor fixation methods, insufficient knowledge of PCL anatomy, improper tunnel placement, and poor surgical candidates.
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Abstract
This article reviews the evidence for the roles of the anterolateral soft-tissue structures in rotatory stability of the knee, including their structural properties, isometry, and contributions to resisting tibial internal rotation. These data then lead to a biomechanical demonstration that the ilio-tibial band is the most important structure for the restraint of anterolateral rotatory instability. Level of evidence V.
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Affiliation(s)
- Andrew A Amis
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, SW7 2AZ, UK.
- Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London School of Medicine, London, W6 8RF, UK.
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Ishigooka H, Campbell ST, Quigley RJ, McGarry MH, Chen YJ, Gupta A, Bui CNH, Lee TQ. Anatomic Posterolateral Corner Reconstruction Using a Fibula Cross-Tunnel Technique: A Cadaveric Biomechanical Study. Arthroscopy 2016; 32:2300-2307. [PMID: 27209620 DOI: 10.1016/j.arthro.2016.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 02/18/2016] [Accepted: 03/11/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical properties of a fibula cross-tunnel technique for posterolateral corner (PLC) reconstruction with those of intact knees. METHODS Seven fresh-frozen cadaveric knees were tested while intact, after PLC tear, and after reconstruction. Testing of the parameters listed above was performed at 0°, 30°, 60°, and 90° of knee flexion. Reconstruction was performed using 2 independent tendon autografts. Afterward, the fibula and graft were loaded to failure. RESULTS Reconstruction restored external rotation (0°: 11.75° ± 2.02° to 9.81° ± 1.81°, P = .57; 30°: 17.91° ± 1.32° to 13.96° ± 2.84°, P = .12; 60°: 15.86° ± 1.68° to 13.26° ± 3.58°, P = .41; 90°: 15.53° ± 1.62° to 14.07° ± 2.95°, P = .54) to the intact state, and posterior translation (0°: 3.66 ± 0.85 mm to 3.31 ± 0.89 mm, P = .87; 60°: 3.15 ± 0.45 mm to 2.96 ± 0.45 mm, P = .73; 90°: 2.74 ± 0.33 mm to 3.05 ± 0.41 mm, P = .41) and varus angulation (0°: 0.92° ± 0.35° to 1.98° ± 0.42°, P = .55; 30°: 2.65° ± 0.27° to 1.09° ± 0.90°, P = .37; 90°: 4.29° ± 0.44° to 2.53° ± 1.13°, P = .19) under most conditions. During load to failure testing, the construct revealed properties similar to those of native structures (yield load: 330.4 ± 45.8 N; ultimate load: 420.9 ± 37.4 N). CONCLUSIONS This technique restored external rotation to the intact state after PLC injury in all testing conditions, as well as posterior translation at 0°, 60°, and 90° of flexion, and varus angulation under all conditions tested except 60° of flexion. CLINICAL RELEVANCE Clinically, this surgical technique may eliminate the need for a tibial tunnel for posterolateral corner reconstruction.
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Affiliation(s)
- Hideya Ishigooka
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of California, Irvine, California, U.S.A.; Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Sean T Campbell
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of California, Irvine, California, U.S.A.; Department of Orthopaedic Surgery, Stanford University, Redwood City, California, U.S.A
| | - Ryan J Quigley
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of California, Irvine, California, U.S.A
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of California, Irvine, California, U.S.A
| | - Yu Jen Chen
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of California, Irvine, California, U.S.A
| | - Akash Gupta
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of California, Irvine, California, U.S.A
| | - Christopher N H Bui
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of California, Irvine, California, U.S.A
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System and University of California, Irvine, California, U.S.A..
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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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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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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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Lam MH, Fong DTP, Yung PSH, Chan KM. Biomechanical techniques to evaluate tibial rotation. A systematic review. Knee Surg Sports Traumatol Arthrosc 2012; 20:1720-9. [PMID: 21912885 DOI: 10.1007/s00167-011-1665-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 09/01/2011] [Indexed: 12/26/2022]
Abstract
PURPOSE This article systematically reviewed the biomechanical techniques to quantify tibial rotation, for an overview of how to choose a suitable technique for specific clinical application. METHODS A systematic search was conducted and finally 110 articles were included in this study. The articles were categorized by the conditions of how the knee was examined: external load application, physical examination and dynamic task. RESULTS The results showed that two-thirds of the included studies measured tibial rotation under external load application, of which over 80% of the experiments employed a cadaveric model. The common techniques used included direct displacement measurement, motion sensor, optical tracking system and universal force moment sensor. Intra-operative navigation system was used to document tibial rotation when the knee was examined by clinical tests. For dynamic assessment of knee rotational stability, motion analysis with skin reflective markers was frequently used although this technique is less accurate due to the skin movement when compared with radiographic measurement. CONCLUSION This study reports various biomechanical measurement techniques to quantify tibial rotation in the literatures. To choose a suitable measurement technique for a specific clinical application, it is suggested to quantify the effectiveness of a new designed surgical technique by using a cadaveric model before applying to living human subjects for intra-operative evaluation or long-time functional stability assessment. Attention should also be paid on the study's purpose, whether to employ a cadaveric model and the way of stress applied to the knee. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Mak-Ham Lam
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Evaluation and management of posterior cruciate ligament injuries. Phys Ther Sport 2012; 13:196-208. [PMID: 23068893 DOI: 10.1016/j.ptsp.2012.03.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 03/27/2012] [Accepted: 03/28/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Posterior cruciate ligament injuries are increasingly recognized, the result of various sports activities, and while most athletes return to sports the development degenerative joint changes is common. OBJECTIVE To provide a synopsis of the current best evidence regarding the recognition and treatment of posterior cruciate ligament injuries. DESIGN Structured narrative review. METHODS Keyword search of Medline, CINAHL, and PEDro databases for studies published in English from January 1975 to July 2011. Additionally, the reference lists from articles obtained were manually searched for relevant literature. SUMMARY The manuscript provides an overview of posterior cruciate ligament injury, discusses diagnostic methods to include radiographic examination techniques, and presents information on surgical and conservative management of PCL injuries. CONCLUSION Understanding the mechanism of injuries and most effective examination methods can aide in effective early recognition of PCL injuries. Appropriate management of the patient with PCL deficiency or reconstructed knee will optimize outcomes and potentially affect long term knee function.
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Lasmar RCP, Marques de Almeida A, Serbino JW, da Mota Albuquerque RF, Hernandez AJ. Importance of the different posterolateral knee static stabilizers: biomechanical study. Clinics (Sao Paulo) 2010; 65:433-40. [PMID: 20454502 PMCID: PMC2862665 DOI: 10.1590/s1807-59322010000400013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 01/15/2009] [Accepted: 01/15/2010] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the relative importance of the different static stabilizers of the posterolateral corner of the knee in cadavers. METHODS Tests were performed with the application of a varus and external rotation force to the knee in extension at 30 and 60 degrees of flexion using 10 cadaver knees. The forces were applied initially to an intact knee and then repeated after a selective sectioning of the ligaments into the following: section of the lateral collateral ligament; section of the lateral collateral ligament and the popliteofibular complex; and section of the lateral collateral ligament, the popliteofibular complex and the posterolateral capsule. The parameters studied were the angular deformity and stiffness when the knees were submitted to a 15 Newton-meter varus torque and a 6 Newton-meter external tibial torque. Statistical analysis was performed using the ANOVA (Analysis of Variance) and Tukey's tests. RESULTS AND CONCLUSION Our findings showed that the lateral collateral ligament was important in varus stability at 0, 30 and 60 degrees. The popliteofibular complex was the most important structure for external rotation stability at all angles of flexion and was also important for varus stability at 30 and 60 degrees. The posterolateral capsule was important for varus stability at 0 and 30 degrees and for external rotation stability in extension. LEVEL OF EVIDENCE Level IV (cadaver study).
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Affiliation(s)
| | - Adriano Marques de Almeida
- Sports Medicine Group of the Orthopedics Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
| | - José Wilson Serbino
- Instituto de Ortopedia e Traumatologia de Roortopedia Porto Velho - Porto Velho//RO, Brazil.,
, Tel: 55 11 3266.5559
| | | | - Arnaldo José Hernandez
- Sports Medicine Group of the Orthopedics Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
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Khan RT, Lie DT, Cashman PM, Thomas RW, Amis AA. Measurement of laxity in the anterior cruciate ligament-deficient knee: A comparison of three different methods in vitro. Proc Inst Mech Eng H 2007; 221:653-63. [DOI: 10.1243/09544119jeim182] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to compare in-vitro measurements of anteroposterior laxity in the anterior cruciate ligament (ACL)-deficient knee using three different methods: an Instron materials-testing machine, then a KT-2000 arthrometer, and finally by Roentgen stereophotogrammetric analysis (RSA). Eight ACL-deficient human cadaver knees were used. Total displacement was measured between 90 N anterior and 90 N posterior tibiofemoral drawer forces at both 20° and 90° knee flexion. Laxity ranged from 11.5 to 27.6 mm at 20° and from 8.7 to 23.9 mm at 90°. A statistically significant difference was not found between the mean RSA and KT-2000 measurements. However, the mean Instron measurements of laxity were significantly (3-4 mm) higher than both RSA and KT-2000 measurements. The clinical methods of RSA and the KT-2000 measurements agreed well but appeared to underestimate tibiofemoral anteroposterior laxity compared with the materials-testing machine. These findings may be helpful in the future comparison of different studies.
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Affiliation(s)
- R T Khan
- Musculoskeletal Surgery, Imperial College London, London, UK
| | - D T Lie
- Department of Mechanical Engineering, Imperial College London, London, UK
| | - P M Cashman
- Department of Bioengineering, Imperial College London, London, UK
| | - R W Thomas
- Musculoskeletal Surgery, Imperial College London, London, UK
| | - A A Amis
- Musculoskeletal Surgery, Imperial College London, London, UK
- Department of Mechanical Engineering, Imperial College London, London, UK
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Grassmayr MJ, Parker DA, Coolican MRJ, Vanwanseele B. Posterior cruciate ligament deficiency: biomechanical and biological consequences and the outcomes of conservative treatment. A systematic review. J Sci Med Sport 2007; 11:433-43. [PMID: 17884727 DOI: 10.1016/j.jsams.2007.07.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Revised: 06/18/2007] [Accepted: 07/30/2007] [Indexed: 10/22/2022]
Abstract
The objective of the study was to evaluate the biomechanical and biological consequences of posterior cruciate ligament deficiency, determine compensatory mechanisms and assess the efficacy of non-operative treatment. Medline, CINAHL, SPORTdiscus, Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched at 30th October 2006 for the terms "PCL" and "posterior cruciate ligament" both independently and including the terms "injury", "deficiency" and "insufficiency". Literature searches identified 598 potentially relevant articles, after exclusions there were 47 articles that fulfilled the inclusion criteria: 30 articles analyzing PCL deficiency and 17 studies on the outcomes for non-operative treatment. The authors reviewed all selected articles and abstracted data into predetermined tables depending upon classification. Studies indicate that posterior cruciate ligament deficiency results in posterior tibial translation with combined injuries displaying greater laxity. Results were inconsistent for rotational stability but deficiency increases joint contact pressure and may result in articular damage. A loss of proprioception occurs but the effect on strength and kinetics is inconclusive. There is a lack of evidence for compensatory muscle activity. Return to activity is possible for the majority of non-operatively treated grade I and II isolated injuries. Comparative analysis was not possible in many instances due to study design or experimental protocols. Further research is required to establish the compensatory mechanisms stabilizing the posterior cruciate ligament deficient knee and to investigate the outcomes for non-operatively treated patients.
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Affiliation(s)
- Matthew J Grassmayr
- School of Exercise and Sport Science, University of Sydney, Sydney, Australia.
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Coobs BR, LaPrade RF, Griffith CJ, Nelson BJ. Biomechanical analysis of an isolated fibular (lateral) collateral ligament reconstruction using an autogenous semitendinosus graft. Am J Sports Med 2007; 35:1521-7. [PMID: 17495013 DOI: 10.1177/0363546507302217] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The fibular collateral ligament is the primary stabilizer to varus instability of the knee. Untreated fibular collateral ligament injuries can lead to residual knee instability and can increase the risk of concurrent cruciate ligament reconstruction graft failures. Anatomic reconstructions of the fibular collateral ligament have not been biomechanically validated. PURPOSE To describe an anatomic fibular collateral ligament reconstruction using an autogenous semitendinosus graft and to test the hypothesis that using this reconstruction technique to treat an isolated fibular collateral ligament injury will restore the knee to near normal stability. STUDY DESIGN Controlled laboratory study. METHODS Ten nonpaired, fresh-frozen cadaveric knees were biomechanically subjected to a 10 N.m varus moment and 5 N.m external and internal rotation torques at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of knee flexion. Testing was performed with an intact and sectioned fibular collateral ligament, and also after an anatomic reconstruction of the fibular collateral ligament with an autogenous semitendinosus graft. Motion changes were assessed with a 6 degree of freedom electromagnetic motion analysis system. RESULTS After sectioning, we found significant increases in varus rotation at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees, external rotation at 60 degrees and 90 degrees, and internal rotation at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of knee flexion. After reconstruction, there were significant decreases in motion in varus rotation at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees, external rotation at 60 degrees and 90 degrees, and internal rotation at 0 degrees, 15 degrees, and 30 degrees of knee flexion. In addition, we observed a full recovery of knee stability in varus rotation at 0 degrees, 60 degrees, and 90 degrees, external rotation at 60 degrees and 90 degrees, and internal rotation at 0 degrees and 30 degrees of knee flexion. CONCLUSION An anatomic fibular collateral ligament reconstruction restores varus, external, and internal rotation to near normal stability in a knee with an isolated fibular collateral ligament injury. CLINICAL SIGNIFICANCE An anatomic reconstruction of the fibular collateral ligament with an autogenous semitendinosus graft is a viable option to treat nonrepairable acute or chronic fibular collateral ligament tears in patients with varus instability.
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Affiliation(s)
- Benjamin R Coobs
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN 55454, USA
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Strauss EJ, Ishak C, Inzerillo C, Walsh M, Yildirim G, Walker P, Jazrawi L, Rosen J. Effect of tibial positioning on the diagnosis of posterolateral rotatory instability in the posterior cruciate ligament-deficient knee. Br J Sports Med 2007; 41:481-5; discussion 485. [PMID: 17261553 PMCID: PMC2465456 DOI: 10.1136/bjsm.2006.030767] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2007] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To determine whether positioning of the tibia affects the degree of tibial external rotation seen during a dial test in the posterior cruciate ligament (PCL)-posterolateral corner (PLC)-deficient knee. DESIGN Laboratory investigation. SETTING Biomechanics laboratory. HYPOTHESIS An anterior force applied to the tibia in the combined PCL-PLC-deficient knee will yield increased tibial external rotation during a dial test. METHODS The degree of tibial external rotation was measured with 5 Nm of external rotation torque applied to the tibia at both 30 degrees and 90 degrees of knee flexion. Before the torque was applied, an anterior force, a posterior force, or neutral (normal, reduced control) force was applied to the tibia. External rotation measurements were repeated after sequential sectioning of the PCL, the posterolateral structures and the fibular collateral ligament (FCL). RESULTS Baseline testing of the intact specimens demonstrated a mean external rotation of 18.6 degrees with the knee flexed to 30 degrees (range 16.1-21.0 degrees ), and a mean external rotation of 17.3 degrees with the knee flexed to 90 degrees (range 13.8-20.0 degrees ). Sequential sectioning of the PCL, popliteus and popliteofibular ligament, and the FCL led to a significant increase in tibial external rotation compared with the intact knee for all testing scenarios. After sectioning of the popliteus and popliteofibular ligament, the application of an anterior force during testing led to a mean tibial external rotation that was 5 degrees greater than during testing in the neutral position and 7.5 degrees greater than during testing with a posterior force. In the PCL, popliteus/popliteofibular ligament and FCL-deficient knee, external rotation was 9 degrees and 12 degrees greater with the application of an anterior force during testing compared with neutral positioning and the application of a posterior force, respectively. CONCLUSION An anterior force applied to the tibia during the dial test in a combined PCL-PLC-injured knee increased the overall amount of observed tibial external rotation during the dial test. The anterior force reduced the posterior tibial subluxation associated with PCL injury, which is analogous to what is observed when the dial test is performed with the patient in the prone position. Reducing the tibia with either an anterior force when the patient is supine or performing the dial test with the patient in the prone position increases the ability of an examiner to detect a concomitant PLC injury in the setting of a PCL-deficient knee.
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Affiliation(s)
- Eric J Strauss
- Sports Medicine Service, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York 10003, USA
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Sheehan FT. The finite helical axis of the knee joint (a non-invasive in vivo study using fast-PC MRI). J Biomech 2007; 40:1038-47. [PMID: 17141789 DOI: 10.1016/j.jbiomech.2006.04.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Accepted: 04/05/2006] [Indexed: 10/23/2022]
Abstract
An understanding of the in vivo knee joint kinematics is critical for the further improvement and validation of knee joint models and for the development of better surgical and rehabilitative protocols. Unfortunately, most studies exploring the finite helical axis (FHA) tend to produce excellent qualitative results, but quantitative results are often lacking. Thus, the purpose of this study was to non-invasively and in vivo quantify the tibiofemoral FHA in a relatively large normal population during volitional knee extension using fast-PC MRI, to report the data relative to consistent coordinate systems (making it available for modeling input, experimental comparison and for device design), to determine the variability of the FHA, to investigate the screw home mechanism and to test the hypothesis that knee joint kinematics are independent of gender. Intra- and inter-subject repeatability was excellent. The intra- (inter-) subject repeatability of the FHA orientation in the frontal and axial planes was 1.8% (3.3%) and 3.7% (6.0%) of the average value, respectively. At the beginning of extension, the FHA was directed laterally and slightly superiorly and at the end of extension, it was directed in the lateral-inferior direction, indicative of the screw-home mechanism. The FHA location was not fixed during extension. There was small, but significant differences in all FHA parameters between genders and normalizing positional data relative to epicondylar width helped to reduce this difference. The data obtained in the current study forms an excellent base for future knee joint modeling and clinical studies.
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Affiliation(s)
- Frances T Sheehan
- Physical Disabilities Branch(1), National Institutes of Health, Bethesda, MD, USA.
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Amis AA, Bull AM, Lie DT. Biomechanics of rotational instability and anatomic anterior cruciate ligament reconstruction. ACTA ACUST UNITED AC 2005. [DOI: 10.1053/j.oto.2004.10.009] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Mannel H, Marin F, Claes L, Dürselen L. Anterior cruciate ligament rupture translates the axes of motion within the knee. Clin Biomech (Bristol, Avon) 2004; 19:130-5. [PMID: 14967575 DOI: 10.1016/j.clinbiomech.2003.11.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2003] [Accepted: 11/18/2003] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To quantify the dynamic effects of anterior cruciate ligament deficiency on human knee joint motion. DESIGN Three-dimensional motion was assessed by measuring the kinematics of intact and anterior cruciate ligament deficient knee joint specimens during simulated flexion-extension cycles. BACKGROUND It is known that the anterior cruciate ligament plays an important role in controlling three-dimensional knee joint motion. Nevertheless, dynamic effects of deficiency are not fully understood. METHODS Six cadaveric knees were tested in a knee joint motion and loading apparatus prior to and after anterior cruciate ligament resection. To determine if the kinematic results depended on additional loading, internal and external rotation moments of 3.4 Nm were axially applied to the tibia. The kinematics were analysed in terms of finite helical axes. RESULTS Sectioning the anterior cruciate ligament had little effect on the orientations of the finite helical axes. However, applying moments did affect the axes orientation. In contrast, relative translations of the axes were significantly affected by the deficiency for all rotational moments applied. Referring to the individual knee anatomy the largest translation of 12.5 mm (median) occurred in medial/lateral direction. CONCLUSIONS Anterior cruciate ligament rupture primarily causes a translation of the finite helical axes in medial/lateral direction. Consequently, increased anterior excursion of the tibia occurs (subluxation) and therefore dynamic instability.
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Affiliation(s)
- H Mannel
- Institute of Orthopaedic Research and Biomechanics, Medical Faculty, University of Ulm, Helmholtzstr. 14, 89081 Ulm, Germany.
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Abstract
OBJECTIVES To review the experimental evidence and development of concepts in knee kinematics and to present a synthesis of current theories. DATA SOURCES Historical literature from private collections and published journals, from Galen in 160 AD, and Weber and Weber in 1860, through to current research in knee kinematics, sourced through MEDLINE and CINAHL. STUDY SELECTION Studies of the healthy human knee in vivo and in vitro were included. Other studies were included when relevant, for example, when knee surgery methods have led to a change in kinematic concepts. Of 285 items, 94 were included based on their contribution to original research. When relevant, authors were contacted to resolve issues. DATA EXTRACTION Sources included were descriptive studies, anatomic dissections, controlled experimental designs, editorials, and review articles. DATA SYNTHESIS The axes of rotation of the knee are fundamental to kinematic models. The hinge model is contradicted by the ellipsoid shape of the femoral condyles, which results in a moving instant center of motion. However, the "instant center of motion" model was based on analysis of sagittal sections, oblique to the plane of movement and neglecting rotation. The four-bar linkage theory linked cruciate ligament isometry with the roll and glide pattern of knee motion. Recently, however, studies of the biomechanics and histology of the knee ligaments have enabled more accurate kinematic modeling. Three-dimensional imaging and computer modeling have made possible analysis of kinematics parallel to the planes of motion and incorporation of conjoint rotation. Femoral roll back is now described as the manifestation of longitudinal rotation during knee flexion. CONCLUSIONS Current research concludes that the knee has 4 independent axes: patella, posterior condylar, distal condylar, and longitudinal axes. The axes combine to produce the characteristic helical motion of the knee.
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Affiliation(s)
- Paul N Smith
- Trauma and Orthopedic Research Unit, Canberra Hospital, Woden, Canberra, ACT, Australia
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Abstract
The structures within the posterolateral corner of the knee have recently been "re-discovered" providing a very important role in maintaining the stability of the knee. Injury to the posterolateral corner is not common but neither is it rare; it is usually damaged in combination with rupture of one of the cruciate ligaments in direct and indirect trauma to the knee. When reconstructing a knee to restore stability following such injuries, it is important to recognise damage to the posterolateral corner so that this can be corrected. Ignored damage to this region may result in continuing knee instability and resultant failure of cruciate ligament reconstruction. We present a review of the anatomy and biomechanics of the structures in the posterolateral corner. This is then related to the diagnosis of injuries to the region via history, examination and imaging. We then discuss the management of injuries to the posterolateral corner describing our preferred method of repair.
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Affiliation(s)
- Hywel Davies
- The Windsor Knee Clinic, Essex Lodge, 69 Osbourne Road, Windsor SL4 3EQ, UK.
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Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy 2003; 19:262-8. [PMID: 12627150 DOI: 10.1053/jars.2003.50037] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The goal of this study was to gain more information on the likelihood of developing cartilage lesions in posterior cruciate ligament (PCL)-deficient knees. TYPE OF STUDY Retrospective clinical study. METHODS Standardized arthroscopy records of 181 patients with a nonsurgically treated acute or chronic PCL injury were analyzed with respect to cartilage degeneration. Subgroups with different duration of PCL insufficiency, the influence of isolated PCL or combined PCL/posterolateral instability, and the grade of posterior laxity was analyzed. RESULTS PCL insufficiency significantly increased the risk of developing medial femoral condyle and patellar cartilage degeneration over time. Of patients whose PCL deficiency was present for more than 5 years, 77.8% showed degenerative cartilage lesions of the medial femoral condyle and 46.7% showed cartilage degeneration of the patella. After 1 year of PCL insufficiency, the number of medial femoral cartilage lesions increased threefold (13.6% v 39.1%). With the presence of combined PCL/posterolateral insufficiency the amount of medial femoral degeneration was significantly increased (36.6% v 60.6%). CONCLUSIONS We found that PCL insufficiency is not a benign injury with respect to the development of degenerative articular cartilage lesions. The early and continuous increase in cartilage degeneration at the medial femoral condyle and the patella should be considered when discussing operative versus conservative treatment for a PCL-deficient knee. The rapid development of medial arthritis should also be considered during decision making, particularly in patients with combined PCL/posterolateral instability or those who underwent previous partial medial menisectomy.
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Affiliation(s)
- Michael J Strobel
- Orthopädische Gemeinschaftspraxis, Straubing, Charité Campus Virchow Clinic, Humboldt-University, Berlin, Germany.
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Larson RV. Clinical evaluation of posterior cruciate ligament and posterolateral corner insufficiency. OPER TECHN SPORT MED 2001. [DOI: 10.1053/otsm.2001.21760] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
The complex anatomy of the posterolateral corner of the knee is due largely to the evolutionary changes in the anatomic relationships of the fibular head, the popliteus tendon, and the biceps femoris muscle. Recent research has improved our understanding of the popliteus complex, particularly the role of the popliteofibular ligament. Biomechanical studies provide a scientific basis for clinical examination of the knee with suspected injury of the posterolateral corner. All grade-I and most moderate grade-II injuries of the posterolateral structures can be treated nonoperatively, but residual laxity may remain, especially in knees with grade-II injury. Acute grade-III isolated or combined injury of the posterolateral corner is best treated early, by direct repair, if possible, or else by augmentation or reconstruction of all injured ligaments. Chronic injury of the posterolateral corner, whether isolated or combined, is probably best treated by reconstruction of the posterolateral corner along with reconstruction of any coexisting cruciate ligament injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a known tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament.
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Affiliation(s)
- D C Covey
- Department of Orthopaedic Surgery, Naval Hospital, Bremerton, Washington 98312-1898, USA.
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