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Morita Y, Tajima T, Yamaguchi N, Yokoe T, Nagasawa M, Ota T, Ouchi K, Chosa E. Risk factors of failure results after double-bundle reconstruction with autogenous hamstring grafts for isolated posterior cruciate ligament rupture cases. Sci Rep 2024; 14:6192. [PMID: 38486115 PMCID: PMC10940282 DOI: 10.1038/s41598-024-56953-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 03/13/2024] [Indexed: 03/18/2024] Open
Abstract
Posterior tibial translation (PTT) after double-bundle posterior cruciate ligament (PCL) reconstruction has sometimes occurred. Purpose of this study is to identify the risk factors for postoperative PTT after double-bundle PCL reconstruction with a hamstring autograft. Comparing the results of bilateral gravity sag view (GSV) at 12 months after surgery, over 5-mm PTT was defined as 'failure' in this study. Of 26 isolated PCL reconstruction cases, over 5-mm PTT was seen in 7 cases (group F: 9.57 ± 1.28 mm), and 19 cases had less than 5 mm (group G: 2.84 ± 1.29 mm). Age, sex, body mass index (BMI), preoperative GSV, posterior slope angle of the tibia, anterolateral bundle (ALB) and posteromedial bundle (PMB) graft diameters, and tibial tunnel diameter were evaluated. The two groups were compared with the 2 × 2 chi-squared test, the Mann Whitney U-test, and Spearman's rank correlation coefficient. Multivariate logistic regression analysis was also performed to determine the risk factor. Statistical significance was indicated as p < 0.01 for correlation with postoperative PTT, and as p < 0.05 for all other comparisons. Mean age (group G 31.8 ± 12.5 vs group F 34.9 ± 15.9 years), sex (male/female: 15/4 vs 3/4), BMI (25.6 ± 4.6 vs 24.9 ± 3.9 kg/m2), preoperative GSV (11.3 ± 2.2 vs 11.6 ± 2.9 mm), PMB diameter (5.37 ± 0.33 vs 5.36 ± 0.48 mm), and tibial tunnel diameter (9.32 ± 0.58 vs 9.29 ± 0.49 mm) showed no significant differences. ALB diameter was significantly greater in group G (7.0 ± 0.5 mm) than in group F (6.5 ± 0.29 mm; p = 0.022). There was also a significant difference in posterior tibial slope angle (group G 9.19 ± 1.94 vs group F 6.54 ± 1.45, p = 0.004). On Spearman rank correlation coefficient analysis, ALB diameter GSV (correlation coefficient: - 0.561, p = 0.003) and posterior tibial slope angle (correlation coefficient: - 0.533, p = 0.005) showed a significant correlation with postoperative PTT. Multivariate logistic regression analysis showed that ALB diameter (OR 19.028; 95% CI 1.082-334.6; p = 0.044) and posterior slope angle of tibia (OR 3.081; 95% CI 1.109-8.556; p = 0.031) were independently associated with postoperative PTT, respectively. In double-bundle PCL reconstruction with hamstring, smaller ALB graft diameter and lower (flatted) tibial slope angle were considered risk factors for postoperative PTT.
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Affiliation(s)
- Yudai Morita
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Takuya Tajima
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.
| | - Nami Yamaguchi
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Takuji Yokoe
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Makoto Nagasawa
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Tomomi Ota
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Kouki Ouchi
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Etsuo Chosa
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
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Ou D, Ye Y, Pan J, Huang Y, Kuang H, Tang S, Huang R, Mo Y, Pan S. Anterior cruciate ligament injury should not be considered a contraindication for medial unicompartmental knee arthroplasty: Finite element analysis. PLoS One 2024; 19:e0299649. [PMID: 38470904 DOI: 10.1371/journal.pone.0299649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024] Open
Abstract
PURPOSE The research objective of this study is to use finite element analysis to investigate the impact of anterior cruciate ligament (ACL) injury on medial unicompartmental knee arthroplasty (UKA) and explore whether patients with ACL injuries can undergo UKA. METHODS Based on the morphology of the ACL, models of ACL with diameters ranging from 1 to 10mm are created. Finite element models of UKA include ACL absence and ACLs with different diameters. After creating a complete finite element model and validating it, four different types of loads are applied to the knee joint. Statistical analysis is conducted to assess the stress variations in the knee joint structure. RESULTS A total of 11 finite element models of UKA were established. Regarding the stress on the ACL, as the diameter of the ACL increased, when a vertical load of 750N was applied to the femur, combined with an anterior tibial load of 105N, the stress on the ACL increased from 2.61 MPa to 4.62 MPa, representing a 77.05% increase. Regarding the equivalent stress on the polyethylene gasket, a notable high stress change was observed. The stress on the gasket remained between 12.68 MPa and 14.33 MPa in all models. the stress on the gasket demonstrated a decreasing trend. The equivalent stress in the lateral meniscus and lateral femoral cartilage decreases, reducing from the maximum stress of 4.71 MPa to 2.61 MPa, with a mean value of 3.73 MPa. This represents a reduction of 44.72%, and the statistical significance is (P < 0.05). However, under the other three loads, there was no significant statistical significance (P > 0.05). CONCLUSION This study suggests that the integrity of the ACL plays a protective role in performing medial UKA. However, this protective effect is limited when performing medial UKA. When the knee joint only has varying degrees of ACL injury, even ACL rupture, and the remaining structures of the knee joint are intact with anterior-posterior stability in the knee joint, it should not be considered a contraindication for medial UKA.
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Affiliation(s)
- Deyan Ou
- Department of Limb and Joint Ward, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
| | - Yongqing Ye
- Department of Medical Imaging Department, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
| | - Jingwei Pan
- Department of Spine Ward, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
| | - Yu Huang
- Department of Spine Ward, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
| | - Haisheng Kuang
- Department of Limb and Joint Ward, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
| | - Shilin Tang
- Department of Spine Ward, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
| | - Richao Huang
- Department of Limb and Joint Ward, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
| | - Yongxin Mo
- Department of Limb and Joint Ward, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
| | - Shixin Pan
- Department of Spine Ward, Wuzhou Red Cross Hospital, Wuzhou, Guangxi Province, China
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Weili S, Qingyang M, Nayun C, Yong M, Yuping Y, Ping L, Yingfang A, Xi G. Patients with isolated posterior cruciate ligament rupture had a higher posterior intercondylar eminence. BMC Musculoskelet Disord 2022; 23:276. [PMID: 35321666 PMCID: PMC8943983 DOI: 10.1186/s12891-022-05189-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 03/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background To evaluate the anatomic geometry of the posterior intercondylar eminence and its association with PCL injury risk. Methods Patients who underwent primary PCL reconstruction from 2015 to 2018 were retrospectively analyzed. The control group included inpatients diagnosed with ACL rupture because of a sports-related accident during the same period, matched by age, gender, height, weight, and side of injury. Measurements of the height of the apex of the posterior intercondylar eminence (HPIE), the slope length (SLPIE) and the slope angle (SAPIE) of the posterior intercondylar eminence were performed using conventional MRI scans assessed by 2 blinded, independent raters. Intraclass correlation coefficients (ICCs) was used to evaluate the consistency of measurement results. Independent sample t tests, Chi-square tests, and logistic analyses were used to compare the two group, with P < 0.05 considered statistically significant. Results Fifty-five patients with PCL rupture met the inclusion criteria and 55 PCL-intact matched controls were included. There were no significant differences between the groups in gender (P = 1.000), limb side (P = 0.848), age (P = 0.291), BMI (P = 0.444) or height (P = 0.290). Inter-observer reproducibility was excellent agreement in HPIE, SLPIE and SAPIE of case and control groups (ICC: HPIE = 0.81, SLPIE = 0.77, SAPIE = 0.85). Patients with PCL rupture had significantly greater HPIE, SAPIE (both P < 0.001), and SLPIE (P < 0.05) than PCL-intact patients. The multivariable analysis showed that HPIE (OR, 1.62 [95% CI, 1.24–2.11], P < 0.001) and SAPIE (OR, 1.17 [95% CI, 1.05–1.31], P < 0.001) were independent factors associated with PCL rupture. Conclusion Through this retrospective observational study, we found that patients with PCL rupture may have a higher posterior intercondylar eminence compared to PCL-intact patients. Level of evidence III.
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Affiliation(s)
- Shi Weili
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Meng Qingyang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Chen Nayun
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Ma Yong
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yang Yuping
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Liu Ping
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Ao Yingfang
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China.
| | - Gong Xi
- Department of Sports Medicine, Peking University Third Hospital. Institute of Sports Medicine of Peking University. Beijing Key Laboratory of Sports Injuries, Beijing, China.
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Kumar A, Sinha S, Arora R, Gaba S, Khan R, Kumar M. The 50 Top-Cited Articles on the Posterior Cruciate Ligament: A Bibliometric Analysis and Review. Orthop J Sports Med 2021; 9:23259671211057851. [PMID: 34881343 PMCID: PMC8647263 DOI: 10.1177/23259671211057851] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/24/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Limited attention has been paid to the natural history, management, and treatment outcomes related to the posterior cruciate ligament (PCL)–deficient knee joint. Purpose: To perform a comprehensive bibliometric analysis to evaluate the 50 top-cited articles in PCL research. Study Design: Cross-sectional study. Methods: We performed a keyword-based search in the Thomson Reuters Web of Science to generate a list of the 50 most cited articles relevant to the PCL. The included articles were analyzed according to journal, country of origin, publication year, total number of citations, citations per year, citation trends, and type of study (clinical vs basic science). Results: The 50 top-cited articles were published between 1975 and 2012, and the number of individual article citations ranged between 98 and 410. The listed articles were published in 7 journals, with the American Journal of Sports Medicine contributing to more than half of the articles and citations. The United States contributed the most articles (84%) and citations (n = 4873). There were 32 clinical studies and 18 basic science studies. All clinical studies had level 4 clinical evidence, and topics included the natural history of PCL tears, factors predicting the need for surgical intervention, and long-term outcomes of isolated PCL injuries and combined capsuloligamentous injuries. Most (77.8%) of the top-cited basic science articles consisted of experimental or biomechanical studies on human cadaveric knees. Conclusion: The current analysis suggests that PCL research is still evolving and needs high-quality prospective evidence to establish sound recommendations.
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Affiliation(s)
- Arvind Kumar
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Siddhartha Sinha
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Rajesh Arora
- Department of Orthopaedics, University College of Medical Sciences, New Delhi, India
| | - Sahil Gaba
- Department of Orthopaedics, Woodend Hospital, Aberdeen, UK
| | - Rizwan Khan
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Mukesh Kumar
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
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任 爽, 时 会, 张 家, 刘 振, 邵 嘉, 朱 敬, 胡 晓, 黄 红, 敖 英. [Finite element analysis of the graft stresses after anterior cruciate ligament reconstruction]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:865-870. [PMID: 34650286 PMCID: PMC8517673 DOI: 10.19723/j.issn.1671-167x.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To explore the stress distribution characteristics of the graft after anterior cruciate ligament (ACL) reconstruction, so as to provide theoretical reference for the surgical plan of ACL reconstruction. METHODS Based on 3D MRI and CT images, finite element models of the uninjured knee joint and knee joint after ACL reconstruction were established in this study. The uninjured knee model included femur, tibia, fibula, medial collateral ligament, lateral collateral ligament, ACL and posterior cruciate ligament. The ACL reconstruction knee model included femur, tibia, fibula, medial collateral ligament, lateral collateral ligament, ACL graft and posterior cruciate ligament. Linear elastic material properties were used for both the uninjured and ACL reconstruction models. The elastic modulus of bone tissue was set as 17 GPa and Poisson' s ratio was 0.36. The material properties of ligament tissue and graft were set as elastic modulus 390 MPa and Poisson's ratio 0.4. The femur was fixed as the boundary condition, and the tibia anterior tension of 134 N was applied as the loading condition. The stress states of the ACL of the intact joint and the ACL graft after reconstruction were solved and analyzed, including tension, pressure, shear force and von Mises stress. RESULTS The maximum compressive stress (6.34 MPa), von Mises stress (5.9 MPa) and shear stress (1.83 MPa) of the reconstructed ACL graft were all at the anterior femoral end. It was consistent with the position of maximum compressive stress (8.77 MPa), von Mises stress (8.88 MPa) and shear stress (3.44 MPa) in the ACL of the intact knee joint. The maximum tensile stress of the graft also appeared at the femoral end, but at the posterior side, which was consistent with the position of the maximum tensile stress of ACL of the uninjured knee joint. More-over, the maximum tensile stress of the graft was only 0.88 MPa, which was less than 2.56 MPa of ACL of the uninjured knee joint. CONCLUSION The maximum compressive stress, von Mises stress and shear stress of the ACL graft are located in the anterior femoral end, and the maximum tensile stress is located in the posterior femoral end, which is consistent with the position of the maximum tensile stress of the ACL of the uninjured knee joint. The anterior part of ACL and the graft bore higher stresses than the posterior part, which is consistent with the biomechanical characteristics of ACL.
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Affiliation(s)
- 爽 任
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 会娟 时
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 家豪 张
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 振龙 刘
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 嘉艺 邵
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 敬先 朱
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 晓青 胡
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 红拾 黄
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 英芳 敖
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
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Wilms LM, Radke KL, Abrar DB, Latz D, Schock J, Frenken M, Windolf J, Antoch G, Filler TJ, Nebelung S. Micro- and Macroscale Assessment of Posterior Cruciate Ligament Functionality Based on Advanced MRI Techniques. Diagnostics (Basel) 2021; 11:1790. [PMID: 34679487 PMCID: PMC8535058 DOI: 10.3390/diagnostics11101790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 12/18/2022] Open
Abstract
T2 mapping assesses tissue ultrastructure and composition, yet the association of imaging features and tissue functionality is oftentimes unclear. This study aimed to elucidate this association for the posterior cruciate ligament (PCL) across the micro- and macroscale and as a function of loading. Ten human cadaveric knee joints were imaged using a clinical 3.0T scanner and high-resolution morphologic and T2 mapping sequences. Emulating the posterior drawer test, the joints were imaged in the unloaded (δ0) and loaded (δ1) configurations. For the entire PCL, its subregions, and its osseous insertion sites, loading-induced changes were parameterized as summary statistics and texture variables, i.e., entropy, homogeneity, contrast, and variance. Histology confirmed structural integrity. Statistical analysis was based on parametric and non-parametric tests. Mean PCL length (37.8 ± 1.8 mm [δ0]; 44.0 ± 1.6 mm [δ1] [p < 0.01]), mean T2 (35.5 ± 2.0 ms [δ0]; 37.9 ± 1.3 ms [δ1] [p = 0.01]), and mean contrast values (4.0 ± 0.6 [δ0]; 4.9 ± 0.9 [δ1] [p = 0.01]) increased significantly under loading. Other texture features or ligamentous, osseous, and meniscal structures remained unaltered. Beyond providing normative T2 values across various scales and configurations, this study suggests that ligaments can be imaged morphologically and functionally based on joint loading and advanced MRI acquisition and post-processing techniques to assess ligament integrity and functionality in variable diagnostic contexts.
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Affiliation(s)
- Lena Marie Wilms
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (K.L.R.); (D.B.A.); (J.S.); (M.F.); (G.A.); (S.N.)
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (D.L.); (J.W.)
| | - Karl Ludger Radke
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (K.L.R.); (D.B.A.); (J.S.); (M.F.); (G.A.); (S.N.)
| | - Daniel Benjamin Abrar
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (K.L.R.); (D.B.A.); (J.S.); (M.F.); (G.A.); (S.N.)
| | - David Latz
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (D.L.); (J.W.)
| | - Justus Schock
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (K.L.R.); (D.B.A.); (J.S.); (M.F.); (G.A.); (S.N.)
| | - Miriam Frenken
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (K.L.R.); (D.B.A.); (J.S.); (M.F.); (G.A.); (S.N.)
| | - Joachim Windolf
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (D.L.); (J.W.)
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (K.L.R.); (D.B.A.); (J.S.); (M.F.); (G.A.); (S.N.)
| | - Timm Joachim Filler
- Institute for Anatomy I, Heinrich-Heine-University, D-40225 Dusseldorf, Germany;
| | - Sven Nebelung
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Hospital of Dusseldorf, D-40225 Dusseldorf, Germany; (K.L.R.); (D.B.A.); (J.S.); (M.F.); (G.A.); (S.N.)
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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: 25] [Impact Index Per Article: 8.3] [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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Abstract
An understanding of knee ligament anatomy and biomechanics is foundational for physicians treating knee injuries, especially the more rare and morbid multiligamentous knee injuries. This chapter examines the roles that the cruciate and collateral anatomy and morphology play in their kinematics. Additionally, the biomechanics of the ACL, PCL, MCL, and LCL are discussed as they have surgical and reconstructive implications.
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9
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Forkel P, Lacheta L, von Deimling C, Lang J, Buchmann L, Imhoff AB, Burgkart R, Willinger L. Modified suture-bridge technique for tibial avulsion fractures of the posterior cruciate ligament: a biomechanical comparison. Arch Orthop Trauma Surg 2020; 140:59-65. [PMID: 31559489 DOI: 10.1007/s00402-019-03278-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Indexed: 02/09/2023]
Abstract
PURPOSE Displaced tibial posterior cruciate ligament (PCL) avulsion fractures require surgical fixation in order to provide an adequate bone healing and to avoid a loss of posterior stability. The purpose of this study was to compare the biomechanical properties of a recently established modified suture bridge technique to a well-established transtibial pullout technique. It was hypothesized that the suture bridge technique shows lower elongation and higher load to failure force compared to a transtibial pullout fixation. METHODS Twelve fresh-frozen human cadaveric knees were biomechanically tested using an uniaxial hydrodynamic material testing system. A standardized bony avulsion fracture of the tibial PCL insertion was generated. Two different techniques were used for fixation: (A) suture bridge configuration and (B) transtibial pullout fixation. In 90° of flexion elongation, initial stiffness and failure load were determined. RESULTS The suture-bridge technique resulted in a significant lower elongation (4.5 ± 2.1 mm) than transtibial pullout technique (12.4 ± 3.0 mm, p < 0.001). The initial stiffness at the beginning of cyclic loading was 46.9 ± 3.9 N/mm in group A und 40.8 ± 9.0 N/mm in group B (p = 0.194). Load to failure testing exhibited 286.8 ± 88.3 N in group A and 234.3 ± 96.8 N in group B (p = 0.377). CONCLUSION The suture bridge technique provides a significant lower construct elongation during cyclic loading. But postoperative rehabilitation must respect the low construct strength of both techniques because both fixation techniques did not show a sufficient fixation strength to allow for a more aggressive rehabilitation.
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Affiliation(s)
- Philipp Forkel
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Lucca Lacheta
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Constantin von Deimling
- Department of Orthopedics and Sports Orthopedics, Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Jan Lang
- Department of Orthopedics and Sports Orthopedics, Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Louis Buchmann
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopedics and Sports Orthopedics, Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Lukas Willinger
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
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10
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Strauss MJ, Varatojo R, Boutefnouchet T, Condello V, Samuelsson K, Gelber PE, Adravanti P, Laver L, Dimmen S, Eriksson K, Verdonk P, Spalding T. The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:1791-1809. [PMID: 30824979 DOI: 10.1007/s00167-019-05426-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/15/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE Currently both autograft and allograft tissues are available for reconstruction of posterior cruciate, collateral and multi-ligament knee injuries. Decision-making is based on a complex interplay between anatomical structures, functional bundles and varying biomechanical requirements. Despite theoretically better biological healing and reduced risk of disease transmission autografts are associated with donor site morbidity as well as being limited by size and quantity. The use of allografts eliminates donor-site morbidity but raises cost and issues of clinical effectiveness. The purpose of this paper is to review current concepts and evidence for the use of allografts in primary posterior cruciate, collateral and multi-ligament reconstructions. METHODS A narrative review of the relevant literature was conducted for PCL, collateral ligament and multi-ligament knee reconstruction. Studies were identified using a targeted and systematic search with focus on recent comparative studies and all clinical systematic reviews and meta-analyses. The rationale and principles of management underpinning the role of allograft tissue were identified and the clinical and functional outcomes were analysed. Finally, the position of postoperative physiotherapy and rehabilitation was identified. RESULTS The review demonstrated paucity in high quality and up-to-date results addressing the issue especially on collaterals and multi-ligament reconstructions. There was no significant evidence of superiority of a graft type over another for PCL reconstruction. Contemporary principles in the management of posterolateral corner, MCL and multi-ligament injuries support the use of allograft tissue. CONCLUSION The present review demonstrates equivalent clinical results with the use of autografts or allografts. It remains, however, difficult to generate a conclusive evidence-based approach due to the paucity of high-level research. When confronted by the need for combined reconstructions with multiple grafts, preservation of synergistic muscles, and adapted postoperative rehabilitation; the current evidence does offer support for the use of allograft tissue. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marc Jacob Strauss
- Steadman Philippon Research Institute, Vail, CO, USA.,Orthopaedic Division, Oslo University Hospital and University of Oslo, Oslo, Norway.,OSTRC, Norwegian School of Sports Sciences, Oslo, Norway
| | | | - Tarek Boutefnouchet
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Vincenzo Condello
- Department of Orthopaedics, Clinica Humanitas Castelli, Via Mazzini, 11, Bergamo, Italy
| | - Kristian Samuelsson
- Sahlgrenska University Hospital, Mölndal, Sweden.,Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pablo E Gelber
- Hospital de la Santa Creu I Sant Pau, Universitat Autònoma Barcelona, Barcelona, Spain.,ICATME-Hospital Universitari Dexeus, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Paolo Adravanti
- Orthopaedic Department, Città di Parma Clinic, Piazzale Athos Maestri 5, Parma, Italy
| | - Lior Laver
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | | | - Karl Eriksson
- Stockholm South Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verdonk
- Antwerp Orthopedic Center, Monica Hospitals, Antwerp, Belgium
| | - Tim Spalding
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK.
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11
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Kim MU, Kim JW, Kim MS, Kim SJ, Yoo OS, In Y. Variation in Graft Bending Angle During Range of Motion in Single-Bundle Posterior Cruciate Ligament Reconstruction: A 3-Dimensional Computed Tomography Analysis of 2 Techniques. Arthroscopy 2019; 35:1183-1194. [PMID: 30871901 DOI: 10.1016/j.arthro.2018.10.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 10/06/2018] [Accepted: 10/29/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare variations in femoral graft bending angle during range of motion (ROM) of the knee between inside-out (IO) and retro-socket outside-in (OI) techniques in posterior cruciate ligament (PCL) reconstruction using in vivo 3-dimensional (3D) computed tomography analysis. METHODS Ten patients underwent PCL reconstruction by the IO technique (5 patients) or the retro-socket OI technique (5 patients) for suspensory femoral fixation. After PCL reconstruction, 3D computed tomography was performed in 0° extension and 90° flexion to reconstruct 3D femur and tibia bone models using Mimics software. Positions of femur and tibia at 30°, 45°, and 60° flexion were reproduced by determining the kinematic factors of anteroposterior translation, mediolateral translation, and internal-external rotation angle of each patient based on previously measured kinematic data. Variation in graft bending angle according to the flexion range of the knee was calculated by the difference in graft angulation measured at each flexion angle. The results were compared between the 2 techniques. RESULTS There was significant difference in variation of femoral graft bending angle between IO and retro-socket OI techniques from 0° to 90° flexion of the knee (P = .008). Significant difference was also noticed at 30° to 45° (P = .008), 45° to 60° (P = .008), and 60° to 90° (P = .016) ROM of the knee between the 2 groups. CONCLUSIONS The retro-socket OI technique resulted in less variation in femoral graft bending angle compared with the IO technique during knee ROM. We recommend the retro-socket OI technique for femoral tunnel placement to reduce the graft motion at the intra-articular femoral tunnel aperture. CLINICAL RELEVANCE The retro-socket OI technique produces significantly less variation in femoral graft bending angle when compared with the IO technique. Such reduction in variation of femoral graft bending angle might be related to lower stress at the femoral tunnel aperture.
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Affiliation(s)
- Min Up Kim
- Department of Orthopedic Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Won Kim
- Central R&D Center, Corentec, Cheonan, Republic of Korea
| | - Man Soo Kim
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Ju Kim
- Central R&D Center, Corentec, Cheonan, Republic of Korea
| | - Oui Sik Yoo
- Central R&D Center, Corentec, Cheonan, Republic of Korea
| | - Yong In
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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12
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Trasolini NA, Lindsay A, Gipsman A, Rick Hatch GF. The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment. Clin Sports Med 2019; 38:215-234. [PMID: 30878045 DOI: 10.1016/j.csm.2018.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee.
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Affiliation(s)
- Nicholas A Trasolini
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA.
| | - Adam Lindsay
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA
| | - Aaron Gipsman
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA
| | - George F Rick Hatch
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA
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13
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Abstract
PURPOSE OF REVIEW The purpose of this review is to present an in-depth look at the most recent literature regarding pertinent posterior cruciate ligament (PCL) anatomy and biomechanics. RECENT FINDINGS The PCL is an important restraint of posterior tibial translation relative to the femur. In addition, the PCL acts as a secondary restraint to resist varus, valgus, and external rotation moments about the knee. While less common than ACL injuries, injuries to the PCL can occur from a posterior force directed on the tibia, most common with the knee in a flexed position. The PCL is composed of two functional bundles and has important implications for knee stability. The anterolateral and posteromedial bundles have different patterns of tensioning throughout knee range of motion. The two bundles therefore contribute to resisting posterior tibial translation and rotation at different angles of knee flexion.
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Affiliation(s)
- Stephanie L Logterman
- Sports Medicine, Department of Orthopedics, University of Colorado School of Medicine, 2150 Stadium Drive, Boulder, CO, 80309, USA
| | - Frank B Wydra
- Sports Medicine, Department of Orthopedics, University of Colorado School of Medicine, 2150 Stadium Drive, Boulder, CO, 80309, USA
| | - Rachel M Frank
- Sports Medicine, Department of Orthopedics, University of Colorado School of Medicine, 2150 Stadium Drive, Boulder, CO, 80309, USA. .,Department of Orthopedic Surgery, University of Colorado School of Medicine, 2631 E. 17th Avenue, Mail Stop B202, Aurora, CO, 80045, USA.
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14
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Wang D, Graziano J, Williams RJ, Jones KJ. Nonoperative Treatment of PCL Injuries: Goals of Rehabilitation and the Natural History of Conservative Care. Curr Rev Musculoskelet Med 2018; 11:290-297. [PMID: 29721691 DOI: 10.1007/s12178-018-9487-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW To review the current practices of nonoperative management of posterior cruciate ligament (PCL) injuries, the natural history of conservative care, and the latest PCL rehabilitation strategies. RECENT FINDINGS PCL injuries often occur as part of a multiligamentous knee injury and occasionally occur in isolation. Although patients may be able to tolerate or compensate for a PCL-deficient knee, long-term outcomes after conservative care demonstrate a high rate of arthrosis in the medial and patellofemoral compartments resulting from altered knee kinematics and loads. Good subjective outcomes and a high rate of return to sport have been reported after nonoperative treatment of isolated PCL injuries. However, PCL laxity grade on objective exam does not typically correlate with subjective outcomes, nor does it correlate with the risk of developing osteoarthritis. Although more research is needed on the optimal PCL rehabilitation strategies, general principles include avoiding posterior tibial translation in the initial period to optimize ligament healing, followed by progressive range of motion and strengthening of the quadriceps and core musculature. At 12 weeks, patients may begin an interval running program, followed by agility work and progressive sports-specific training to allow for return to sports. Nonoperative treatment of isolated PCL injuries results in good subjective outcomes and high rate of return to sport.
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Affiliation(s)
- Dean Wang
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | | | - Riley J Williams
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Kristofer J Jones
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA
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15
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Searching for the “sweet spot”: the foot rotation and parallel engagement of ankle ligaments in maximizing injury tolerance. Biomech Model Mechanobiol 2017. [DOI: 10.1007/s10237-017-0929-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Kobayashi T, Yamakawa S, Watanabe K, Kimura K, Suzuki D, Otsubo H, Teramoto A, Fujimiya M, Fujie H, Yamashita T. The in situ force in the calcaneofibular ligament and the contribution of this ligament to ankle joint stability. Clin Biomech (Bristol, Avon) 2016; 40:8-13. [PMID: 27771606 DOI: 10.1016/j.clinbiomech.2016.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 09/20/2016] [Accepted: 10/13/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Numerous biomechanical studies of the lateral ankle ligaments have been reported; however, the isolated function of the calcaneofibular ligament has not been clarified. We hypothesize that the calcaneofibular ligament would stabilize the ankle joint complex under multidirectional loading, and that the in situ force in the calcaneofibular ligament would change in each flexed position. METHODS Using seven fresh frozen cadaveric lower extremities, the motions and forces of the intact ankle under multidirectional loading were recorded using a 6-degree-of-freedom robotic system. On repeating these intact ankle joint complex motions after the calcaneofibular ligament transection, the in situ force in the calcaneofibular ligament and the contribution of the calcaneofibular ligament to ankle joint complex stability were calculated. Finally, the motions of the calcaneofibular ligament-transected ankle joint complex were recorded. FINDINGS Under an inversion load, significant increases of inversion angle were observed in all the flexed positions following calcaneofibular ligament transection, and the calcaneofibular ligament accounted for 50%-70% of ankle joint complex stability during inversion. The in situ forces in the calcaneofibular ligament under an anterior force, inversion moment, and external rotation moment were larger in the dorsiflexed position than in the plantarflexed position. INTERPRETATION The calcaneofibular ligament plays a role in stabilizing the ankle joint complex to multidirectional loads and the role differs with load directions. The in situ force of the calcaneofibular ligament is larger at the dorsiflexed position. This ligament provides the primary restraint to the inversion ankle stability.
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Affiliation(s)
- Takuma Kobayashi
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1 West-16 Chuo-ku, Sapporo, Hokkaido 060-8543, Japan.
| | - Satoshi Yamakawa
- Biomechanics Laboratory, Faculty of System Design, Tokyo Metropolitan University, 6-6 Asahigaoka, Hino-shi, Tokyo 191-0065, Japan
| | - Kota Watanabe
- Department of Physical Therapy, Sapporo Medical University School of Health Sciences, South-1, West-17, Chuo-ku, Sapporo, Hokkaido 060-8556, Japan
| | - Kei Kimura
- Biomechanics Laboratory, Faculty of System Design, Tokyo Metropolitan University, 6-6 Asahigaoka, Hino-shi, Tokyo 191-0065, Japan
| | - Daisuke Suzuki
- Department of Musculoskeletal Biomechanics and Surgical Development, Sapporo Medical University, South-1 West-16 Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - Hidenori Otsubo
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1 West-16 Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1 West-16 Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - Mineko Fujimiya
- Department of Anatomy, Sapporo Medical University School of Medicine, South-1 West-16 Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - Hiromichi Fujie
- Biomechanics Laboratory, Faculty of System Design, Tokyo Metropolitan University, 6-6 Asahigaoka, Hino-shi, Tokyo 191-0065, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, South-1 West-16 Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
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17
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Loading Patterns of the Posterior Cruciate Ligament in the Healthy Knee: A Systematic Review. PLoS One 2016; 11:e0167106. [PMID: 27880849 PMCID: PMC5120848 DOI: 10.1371/journal.pone.0167106] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/07/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The posterior cruciate ligament (PCL) is the strongest ligament of the knee, serving as one of the major passive stabilizers of the tibio-femoral joint. However, despite a number of experimental and modelling approaches to understand the kinematics and kinetics of the ligament, the normal loading conditions of the PCL and its functional bundles are still controversially discussed. OBJECTIVES This study aimed to generate science-based evidence for understanding the functional loading of the PCL, including the anterolateral and posteromedial bundles, in the healthy knee joint through systematic review and statistical analysis of the literature. DATA SOURCES MEDLINE, EMBASE and CENTRAL. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Databases were searched for articles containing any numerical strain or force data on the healthy PCL and its functional bundles. Studied activities were as follows: passive flexion, flexion under 100N and 134N posterior tibial load, walking, stair ascent and descent, body-weight squatting and forward lunge. METHOD Statistical analysis was performed on the reported load data, which was weighted according to the number of knees tested to extract average strain and force trends of the PCL and identify deviations from the norms. RESULTS From the 3577 articles retrieved by the initial electronic search, only 66 met all inclusion criteria. The results obtained by aggregating data reported in the eligible studies indicate that the loading patterns of the PCL vary with activity type, knee flexion angle, but importantly also the technique used for assessment. Moreover, different fibres of the PCL exhibit different strain patterns during knee flexion, with higher strain magnitudes reported in the anterolateral bundle. While during passive flexion the posteromedial bundle is either lax or very slightly elongated, it experiences higher strain levels during forward lunge and has a synergetic relationship with the anterolateral bundle. The strain patterns obtained for virtual fibres that connect the origin and insertion of the bundles in a straight line show similar trends to those of the real bundles but with different magnitudes. CONCLUSION This review represents what is now the best available understanding of the biomechanics of the PCL, and may help to improve programs for injury prevention, diagnosis methods as well as reconstruction and rehabilitation techniques.
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18
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Nie B, Panzer MB, Mane A, Mait AR, Donlon JP, Forman JL, Kent RW. Determination of the in situ mechanical behavior of ankle ligaments. J Mech Behav Biomed Mater 2016; 65:502-512. [PMID: 27665085 DOI: 10.1016/j.jmbbm.2016.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/26/2016] [Accepted: 09/07/2016] [Indexed: 11/16/2022]
Abstract
The mechanical behavior of ankle ligaments at the structural level can be characterized by force-displacement curves in the physiologic phase up to the initiation of failure. However, these properties are difficult to characterize in vitro due to the experimental difficulties in replicating the complex geometry and non-uniformity of the loading state in situ. This study used a finite element parametric modeling approach to determine the in situ mechanical behavior of ankle ligaments at neutral foot position for a mid-sized adult foot from experimental derived bony kinematics. Nine major ankle ligaments were represented as a group of fibers, with the force-elongation behavior of each fiber element characterized by a zero-force region and a region of constant stiffness. The zero-force region, representing the initial tension or slackness of the whole ligament and the progressive fiber uncrimping, was identified against a series of quasi-static experiments of single foot motion using simultaneous optimization. A range of 0.33-3.84mm of the zero-force region was obtained, accounting for a relative length of 6.7±3.9%. The posterior ligaments generally exhibit high-stiffness in the loading region. Following this, the ankle model implemented with in situ ligament behavior was evaluated in response to multiple loading conditions and proved capable of predicting the bony kinematics accurately in comparison to the cadaveric response. Overall, the parametric ligament modeling demonstrated the feasibility of linking the gross structural behavior and the underlying bone and ligament mechanics that generate them. Determination of the in situ mechanical properties of ankle ligaments provides a better understanding of the nonlinear nature of the ankle joint. Applications of this knowledge include functional ankle joint mechanics and injury biomechanics.
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Affiliation(s)
- Bingbing Nie
- Center for Applied Biomechanics, University of Virginia, 4040 Lewis and Clark Drive, Charlottesville, VA 22911, USA.
| | - Matthew B Panzer
- Center for Applied Biomechanics, University of Virginia, 4040 Lewis and Clark Drive, Charlottesville, VA 22911, USA
| | - Adwait Mane
- Center for Applied Biomechanics, University of Virginia, 4040 Lewis and Clark Drive, Charlottesville, VA 22911, USA
| | - Alexander R Mait
- Center for Applied Biomechanics, University of Virginia, 4040 Lewis and Clark Drive, Charlottesville, VA 22911, USA
| | - John-Paul Donlon
- Center for Applied Biomechanics, University of Virginia, 4040 Lewis and Clark Drive, Charlottesville, VA 22911, USA
| | - Jason L Forman
- Center for Applied Biomechanics, University of Virginia, 4040 Lewis and Clark Drive, Charlottesville, VA 22911, USA
| | - Richard W Kent
- Center for Applied Biomechanics, University of Virginia, 4040 Lewis and Clark Drive, Charlottesville, VA 22911, USA
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19
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Richard V, Lamberto G, Lu TW, Cappozzo A, Dumas R. Knee Kinematics Estimation Using Multi-Body Optimisation Embedding a Knee Joint Stiffness Matrix: A Feasibility Study. PLoS One 2016; 11:e0157010. [PMID: 27314586 PMCID: PMC4912111 DOI: 10.1371/journal.pone.0157010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 05/23/2016] [Indexed: 11/18/2022] Open
Abstract
The use of multi-body optimisation (MBO) to estimate joint kinematics from stereophotogrammetric data while compensating for soft tissue artefact is still open to debate. Presently used joint models embedded in MBO, such as mechanical linkages, constitute a considerable simplification of joint function, preventing a detailed understanding of it. The present study proposes a knee joint model where femur and tibia are represented as rigid bodies connected through an elastic element the behaviour of which is described by a single stiffness matrix. The deformation energy, computed from the stiffness matrix and joint angles and displacements, is minimised within the MBO. Implemented as a "soft" constraint using a penalty-based method, this elastic joint description challenges the strictness of "hard" constraints. In this study, estimates of knee kinematics obtained using MBO embedding four different knee joint models (i.e., no constraints, spherical joint, parallel mechanism, and elastic joint) were compared against reference kinematics measured using bi-planar fluoroscopy on two healthy subjects ascending stairs. Bland-Altman analysis and sensitivity analysis investigating the influence of variations in the stiffness matrix terms on the estimated kinematics substantiate the conclusions. The difference between the reference knee joint angles and displacements and the corresponding estimates obtained using MBO embedding the stiffness matrix showed an average bias and standard deviation for kinematics of 0.9±3.2° and 1.6±2.3 mm. These values were lower than when no joint constraints (1.1±3.8°, 2.4±4.1 mm) or a parallel mechanism (7.7±3.6°, 1.6±1.7 mm) were used and were comparable to the values obtained with a spherical joint (1.0±3.2°, 1.3±1.9 mm). The study demonstrated the feasibility of substituting an elastic joint for more classic joint constraints in MBO.
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Affiliation(s)
- Vincent Richard
- Univ Lyon, Université Claude Bernard Lyon 1, IFSTTAR, UMR_T9406, LBMC, F69622, Lyon, France
- Università degli Studi di Roma – Foro Italico, Department of Movement, Human, and Health Sciences, Rome, Italy
| | - Giuliano Lamberto
- University of Sheffield, Department of Mechanical Engineering and INSIGNEO Institute for in Silico Medicine, Sheffield, United Kingdom
| | - Tung-Wu Lu
- National Taiwan University, Institute of Biomedical Engineering, Taipei, Taiwan
- National Taiwan University, Department of Orthopaedic Surgery, Taipei, Taiwan
| | - Aurelio Cappozzo
- Università degli Studi di Roma – Foro Italico, Department of Movement, Human, and Health Sciences, Rome, Italy
| | - Raphaël Dumas
- Univ Lyon, Université Claude Bernard Lyon 1, IFSTTAR, UMR_T9406, LBMC, F69622, Lyon, France
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20
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Kim HS, Yoon YC, Park KJ, Wang JH, Choe BK. Interposition of the Posterior Cruciate Ligament into the Medial Compartment of the Knee Joint on Coronal Magnetic Resonance Imaging. Korean J Radiol 2016; 17:239-44. [PMID: 26957909 PMCID: PMC4781763 DOI: 10.3348/kjr.2016.17.2.239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 01/04/2016] [Indexed: 12/02/2022] Open
Abstract
Objective The purpose of our study was to evaluate the overall prevalence and clinical significance of interposition of the posterior cruciate ligament (PCL) into the medial compartment of the knee joint in coronal magnetic resonance imaging (MRI). Materials and Methods We retrospectively reviewed 317 consecutive patients referred for knee MRI at our institution between October 2009 and December 2009. Interposition of the PCL into the medial compartment of the knee joint on proton coronal MRI was evaluated dichotomously (i.e., present or absent). We analyzed the interposition according to its prevalence as well as its relationship with right-left sidedness, gender, age, and disease categories (osteoarthritis, anterior cruciate ligament tear, and medial meniscus tear). Results Prevalence of interposition of PCL into the medial compartment of the knee joint was 47.0% (149/317). There was no right (50.0%, 83/166) to left (43.7%, 66/151) or male (50.3%, 87/173) to female (43.1%, 62/144) differences in the prevalence. There was no significant association between the prevalence and age, or the disease categories. Conclusion Interposition of the PCL into the medial compartment of the knee joint is observed in almost half of patients on proton coronal MRI of the knee. Its presence is not associated with any particular factors including knee pathology and may be regarded as a normal MR finding.
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Affiliation(s)
- Hyun Su Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Young Cheol Yoon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.; Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul 06351, Korea
| | - Ki Jeong Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Joon Ho Wang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Bong-Keun Choe
- Department of Preventive Medicine, Kyung Hee University School of Medicine, Seoul 02454, Korea
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LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging Updates on the Posterior Cruciate Ligament: A Review of the Current Literature. Am J Sports Med 2015; 43:3077-92. [PMID: 25776184 DOI: 10.1177/0363546515572770] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The posterior cruciate ligament (PCL) is recognized as an essential stabilizer of the knee. However, the complexity of the ligament has generated controversy about its definitive role and the recommended treatment after injury. A proper understanding of the functional role of the PCL is necessary to minimize residual instability, osteoarthritic progression, and failure of additional concomitant ligament graft reconstructions or meniscal repairs after treatment. Recent anatomic and biomechanical studies have elucidated the surgically relevant quantitative anatomy and confirmed the codominant role of the anterolateral and posteromedial bundles of the PCL. Although nonoperative treatment has historically been the initial treatment of choice for isolated PCL injury, possibly biased by the historically poorer objective outcomes postoperatively compared with anterior cruciate ligament reconstructions, surgical intervention has been increasingly used for isolated and combined PCL injuries. Recent studies have more clearly elucidated the biomechanical and clinical effects after PCL tears and resultant treatments. This article presents a thorough review of updates on the clinically relevant anatomy, epidemiology, biomechanical function, diagnosis, and current treatments for the PCL, with an emphasis on the emerging clinical and biomechanical evidence regarding each of the treatment choices for PCL reconstruction surgery. It is recommended that future outcomes studies use PCL stress radiographs to determine objective outcomes and that evidence level 1 and 2 studies be performed to assess outcomes between transtibial and tibial inlay reconstructions and also between single- and double-bundle PCL reconstructions.
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Affiliation(s)
| | | | | | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
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LaPrade RF, Smith SD, Wilson KJ, Wijdicks CA. Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: an in vivo investigation. Knee Surg Sports Traumatol Arthrosc 2015; 23:3070-6. [PMID: 25145947 DOI: 10.1007/s00167-014-3238-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 08/11/2014] [Indexed: 12/01/2022]
Abstract
PURPOSE Counteracting posterior translation of the tibia with an anterior force on the posterior proximal tibia has been demonstrated clinically to improve posterior knee laxity following posterior cruciate ligament (PCL) injury. This study quantified forces applied to the posterior proximal tibia by two knee braces designed for treatment of PCL injuries. METHODS The forces applied by two knee braces to the posterior proximal tibia and in vivo three-dimensional knee kinematics of six adult, male, healthy volunteer subjects (mean ± standard deviation: height, 182.5 ± 5.2 cm; body mass, 83.2 ± 9.3 kg; body mass index, 24.9 ± 1.5 kg/m(2); age, 25.8 ± 2.9 years) were measured using a custom pressure mapping technique and traditional surface marker motion capture techniques, while subjects performed three functional activities. The activities included seated unloaded knee flexion, squatting, and stair descent in a new generation dynamic force (DF) PCL brace and a static force (SF) PCL brace. RESULTS During unloaded flexion at the lowest force level setting, the force applied by the DF brace increased as a function of flexion angle (slope = 0.7 N/°; p < 0.001) compared to the SF brace effect. Force applied by the SF brace did not significantly change as a function of flexion angle (slope = 0.0 N/°; n.s.). By 45° of flexion, the average force applied by the DF brace (48.1 N) was significantly larger (p < 0.001) than the average force applied by the SF brace (25.0 N). The difference in force continued to increase as flexion angle increased. During stair descent, average force (mean ± standard deviation) at toe off was significantly higher (p = 0.013) for the DF brace (78.7 ± 21.6 N) than the SF brace (37.3 ± 7.2 N). Similar trends were observed for squatting and for the higher force level settings. CONCLUSIONS The DF brace applied forces to the posterior proximal tibia that dynamically increased with increased flexion angle. Additionally, the DF brace applied significantly larger forces at higher flexion angles compared to the SF brace where the PCL is known to experience larger in situ forces. Clinical studies are necessary to determine whether the loading characteristics of the DF brace, which more closely replicated the in situ loading profile of the native PCL, results in long-term improved posterior knee laxity following PCL injury. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Robert F LaPrade
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA. .,The Steadman Clinic, Vail, CO, USA.
| | - Sean D Smith
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Katharine J Wilson
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Coen A Wijdicks
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
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Intraoperative laxity measurements using a navigation system in anatomical double-bundle posterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:3085-93. [PMID: 25377192 DOI: 10.1007/s00167-014-3418-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 10/30/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The objective of this study was to evaluate knee kinematics during double-bundle posterior cruciate ligament reconstruction (DB-PCLR) intraoperatively using a navigation system, and especially assess biomechanical behaviour of the anterolateral bundle (ALB) and posteromedial bundle (PMB) graft in DB-PCLR. Also, clinical results of minimum 2-year follow-up were investigated. METHODS Nine patients received DB-PCLR with hamstring graft. Before reconstruction, knee laxities, including posterior tibial translation (PTT) in neutral rotation at 15°, 30°, 45°, 60°, 75° and 90° of knee flexion, were measured using a kinematic-based navigation system. After the PMB or ALB was temporally fixed, the knee laxities were measured in the same manner. Each patient was evaluated pre- and post-operatively with side-to-side difference of tibial position in gravity sag view and Lysholm score. RESULTS Both ALB and PMB fixation restrained the PTT compared to PCL deficiency throughout all knee flexion angles. At 90° of knee flexion, ALB fixation significantly decreased PTT compare to PMB fixation (p = 0.014) and DB-PCLR significantly decreased PTT compare to ALB fixation (p = 0.045). The mean side-to-side difference of tibial position in gravity sag view was 12.0 ± 1.7 mm preoperatively and 2.3 ± 1.8 mm at final follow-up, and the mean Lysholm scores were 68.9 ± 20.9 and 96.3 ± 2.9, respectively. CONCLUSIONS There were no significant differences in the PTT between ALB and PMB fixations at 0° to 75° of knee flexion, and both ALB and PMB reconstructions are important for restraining PTT. At 90° of knee flexion, the ALB grafts may be more important to control PTT compared to PMB grafts; however, neither single-bundle reconstruction with ALB nor PMB could function as DB-PCLR did. In addition, PTT after DB-PCLR was strongly correlated side-to-side difference in posterior sag view at the final follow-up. The results from this study indicated that both ALB and PMB are important to stabilize PCL-deficient knees. LEVEL OF EVIDENCE Therapeutic study, Level III.
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The effect of graft strength on knee laxity and graft in-situ forces after posterior cruciate ligament reconstruction. PLoS One 2015; 10:e0127293. [PMID: 26001045 PMCID: PMC4441446 DOI: 10.1371/journal.pone.0127293] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/13/2015] [Indexed: 11/19/2022] Open
Abstract
Surgical reconstruction is generally recommended for posterior cruciate ligament (PCL) injuries; however, the use of grafts is still a controversial problem. In this study, a three-dimensional finite element model of the human tibiofemoral joint with articular cartilage layers, menisci, and four main ligaments was constructed to investigate the effects of graft strengths on knee kinematics and in-situ forces of PCL grafts. Nine different graft strengths with stiffness ranging from 0% (PCL rupture) to 200%, in increments of 25%, of an intact PCL's strength were used to simulate the PCL reconstruction. A 100 N posterior tibial drawer load was applied to the knee joint at full extension. Results revealed that the maximum posterior translation of the PCL rupture model (0% stiffness) was 6.77 mm in the medial compartment, which resulted in tibial internal rotation of about 3.01°. After PCL reconstruction with any graft strength, the laxity of the medial tibial compartment was noticeably improved. Tibial translation and rotation were similar to the intact knee after PCL reconstruction with graft strengths ranging from 75% to 125% of an intact PCL. When the graft's strength surpassed 150%, the medial tibia moved forward and external tibial rotation greatly increased. The in-situ forces generated in the PCL grafts ranged from 13.15 N to 75.82 N, depending on the stiffness. In conclusion, the strength of PCL grafts have has a noticeable effect on anterior-posterior translation of the medial tibial compartment and its in-situ force. Similar kinematic response may happen in the models when the PCL graft's strength lies between 75% and 125% of an intact PCL.
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Graft tension of the posterior cruciate ligament using a finite element model. Knee Surg Sports Traumatol Arthrosc 2014; 22:2057-63. [PMID: 23851970 DOI: 10.1007/s00167-013-2609-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 07/04/2013] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of the study was to analyse the change in length and tension of the reconstructed single-bundle posterior cruciate ligament (PCL) with three different femoral tunnels at different knee flexion angles by use of three-dimensional finite element method. METHODS The right knees of 12 male subjects were scanned with a high-resolution computed tomography scanner at four different knee flexion angles (0°, 45°, 90° and 135°). Three types of single-bundle PCL reconstruction were then conducted in a 90° flexion model: femoral tunnels were created in anterolateral (AL), central and posteromedial (PM) regions of the footprint. Length versus flexion curves and tension versus flexion curves were generated. RESULTS Between 0° and 90° of knee flexion, changes in length and tension in the PM grafts were not significant. Whereas the lengths and tension of the AL and central grafts significantly increased in the same flexion range. The length and tension of the PM grafts at 135° of knee flexion were significantly higher than those at 90° of knee flexion, whereas the AL and the central grafts showed only slight length changes beyond 90° of flexion. However, the tension of the AL graft increased significantly beyond 90° of flexion. CONCLUSIONS Changes in the graft length, and tension were generally affected by different femoral tunnels and knee flexion angles. In groups with the AL and PM single-bundle reconstruction, the graft tension increased beyond 90° of knee flexion when the graft is tensioned at 90° of flexion. These data suggest that final fixation angle at 90° for the AL or PM graft would induce graft overtension in high knee flexion of 135°. Whereas central graft which is fixed in 90° of flexion is desirable in terms of prevention of graft overtension. Because the graft tension within it was relatively constant beyond 90° of flexion.
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Weber AE, Bissell B, Wojtys EM, Sekiya JK. Is the all-arthroscopic tibial inlay double-bundle PCL reconstruction a viable option in multiligament knee injuries? Clin Orthop Relat Res 2014; 472:2667-79. [PMID: 25048278 PMCID: PMC4117873 DOI: 10.1007/s11999-014-3796-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND All-arthroscopic tibial inlay double-bundle (DB) posterior cruciate ligament (PCL) reconstruction avoids an open dissection and the "killer turn" while maintaining the advantage of an anatomic graft. However, clinical data on the viability of this surgical technique in multiligamentous knee injuries are lacking. QUESTIONS/PURPOSES At greater than 2 years of followup, we evaluated (1) validated outcomes scores; (2) range of motion; and (3) side-to-side stability on PCL stress radiographs of a small group of patients who underwent all-arthroscopic tibial inlay DB PCL reconstruction in multiligamentous knee injuries, either shortly after injury or late. METHODS All patients sustaining an operative multiligamentous knee injury between August 2007 and March 2009 underwent PCL reconstruction with the all-arthroscopic tibial inlay DB PCL reconstruction. Twelve patients sustained such injuries and were reconstructed during the study period and all 12 returned for followup with a minimum of 2 years (mean 3 ± 0.8 years). There were nine males and three females, with a mean age of 30 years; four patients had a subacute reconstruction (≥ 3 weeks, but < 3 months), and eight patients had chronic reconstructions (> 3 months). Mean time from injury to PCL reconstruction was 7 ± 12 months. Demographics, ROM, outcome scores (Lysholm and International Knee Documentation Committee [IKDC] scores), and PCL stress views were obtained. RESULTS At final followup, mean Lysholm and IKDC subjective scores were 79 ± 16 and 72 ± 19, respectively. IKDC objective scores included eight nearly normal knees, three abnormal knees, and one severely abnormal knee. Mean flexion and extension losses compared with the contralateral were 10 ± 9 and 1 ± 2, respectively. Mean ± SD final side-to-side difference on PCL stress radiographs was 5 ± 3 mm. CONCLUSIONS The clinical and radiographic results of the all-arthroscopic tibial inlay DB PCL reconstruction appear comparable to the same technique in isolated PCL injuries and, based on similar published case series, comparable to results of multiligamentous knee reconstructions using other PCL reconstruction techniques. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander E. Weber
- Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby A, Ann Arbor, MI 48106 USA
| | - Benjamin Bissell
- Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby A, Ann Arbor, MI 48106 USA
| | - Edward M. Wojtys
- Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby A, Ann Arbor, MI 48106 USA
| | - Jon K. Sekiya
- Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby A, Ann Arbor, MI 48106 USA
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Sasaki N, Farraro KF, Kim KE, Woo SLY. Biomechanical evaluation of the quadriceps tendon autograft for anterior cruciate ligament reconstruction: a cadaveric study. Am J Sports Med 2014; 42:723-30. [PMID: 24401682 PMCID: PMC4144981 DOI: 10.1177/0363546513516603] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recently, many surgeons have chosen the quadriceps tendon (QT) as an autograft for anterior cruciate ligament (ACL) reconstruction. However, there have not been biomechanical studies that quantitatively evaluated knee function after reconstruction using a QT autograft. PURPOSE To measure the 6 degrees of freedom knee kinematics and in situ graft forces after reconstruction with a QT autograft compared with a quadrupled semitendinosus and gracilis (QSTG) tendon autograft. STUDY DESIGN Controlled laboratory study. METHODS Ten human cadaveric knees (age, 54-64 years) were tested in 3 conditions: (1) intact, (2) ACL deficient, and (3) after ACL reconstruction using a QT or QSTG autograft. With use of a robotic/universal force-moment sensor testing system, knee kinematics and in situ forces in the ACL and autografts were obtained at 5 knee flexion angles under externally applied loads: (1) 134-N anterior tibial load, (2) 134-N anterior tibial load with 200-N axial compression, and (3) 10-N·m valgus and 5-N·m internal tibial torque. RESULTS Under the anterior tibial load, both autografts restored anterior tibial translation to within 2.5 mm of the intact knee and in situ forces to within 20 N of the intact ACL at 15°, 30°, and 60°. Adding compression did not change these findings. With the combined rotatory load, the anterior tibial translation and graft in situ forces were again not significantly different from the intact ACL. There were no significant differences between the grafts under any experimental condition. CONCLUSION Reconstruction of the ACL with a QT autograft restored knee function to similar levels as that reconstructed with a QSTG autograft under loads simulating clinical examinations. CLINICAL RELEVANCE The positive biomechanical results of this cadaveric study lend support to the use of a QT autograft for ACL reconstruction, as it could restore knee function immediately after surgery under applied loads that mimic clinical examinations.
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Affiliation(s)
- Norihiro Sasaki
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathryn F. Farraro
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kwang E. Kim
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Savio L-Y. Woo
- Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA,Address correspondence to Savio L-Y. Woo, PhD, DSc (Hon), DEng (Hon), Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219 (
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Influence of bundle diameter and attachment point on kinematic behavior in double bundle anterior cruciate ligament reconstruction using computational model. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2014; 2014:948292. [PMID: 24516506 PMCID: PMC3910120 DOI: 10.1155/2014/948292] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 12/13/2013] [Accepted: 12/16/2013] [Indexed: 11/18/2022]
Abstract
A protocol to choose the graft diameter attachment point of each bundle has not yet been determined since they are usually dependent on a surgeon's preference. Therefore, the influence of bundle diameters and attachment points on the kinematics of the knee joint needs to be quantitatively analyzed. A three-dimensional knee model was reconstructed with computed tomography images of a 26-year-old man. Based on the model, models of double bundle anterior cruciate ligament (ACL) reconstruction were developed. The anterior tibial translations for the anterior drawer test and the internal tibial rotation for the pivot shift test were investigated according to variation of bundle diameters and attachment points. For the model in this study, the knee kinematics after the double bundle ACL reconstruction were dependent on the attachment point and not much influenced by the bundle diameter although larger sized anterior-medial bundles provided increased stability in the knee joint. Therefore, in the clinical setting, the bundle attachment point needs to be considered prior to the bundle diameter, and the current selection method of graft diameters for both bundles appears justified.
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Revolutionizing orthopaedic biomaterials: The potential of biodegradable and bioresorbable magnesium-based materials for functional tissue engineering. J Biomech 2013; 47:1979-86. [PMID: 24373510 DOI: 10.1016/j.jbiomech.2013.12.003] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 11/18/2013] [Accepted: 12/01/2013] [Indexed: 02/08/2023]
Abstract
In recent years, there has been a surge of interest in magnesium (Mg) and its alloys as biomaterials for orthopaedic applications, as they possess desirable mechanical properties, good biocompatibility, and biodegradability. Also shown to be osteoinductive, Mg-based materials could be particularly advantageous in functional tissue engineering to improve healing and serve as scaffolds for delivery of drugs, cells, and cytokines. In this paper, we will present two examples of Mg-based orthopaedic devices: an interference screw to accelerate ACL graft healing and a ring to aid in the healing of an injured ACL. In vitro tests using a robotic/UFS testing system showed that both devices could restore function of the goat stifle joint. Under a 67-N anterior tibial load, both the ACL graft fixed with the Mg-based interference screw and the Mg-based ring-repaired ACL could restore anterior tibial translation (ATT) to within 2mm and 5mm, respectively, of the intact joint at 30°, 60°, and 90° of flexion. In-situ forces in the replacement graft and Mg-based ring-repaired ACL were also similar to those of the intact ACL. Further, early in vivo data using the Mg-based interference screw showed that after 12 weeks, it was non-toxic and the joint stability and graft function reached similar levels as published data. Following these positive results, we will move forward in incorporating bioactive molecules and ECM bioscaffolds to these Mg-based biomaterials to test their potential for functional tissue engineering of musculoskeletal and other tissues.
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Kennedy NI, Wijdicks CA, Goldsmith MT, Michalski MP, Devitt BM, Årøen A, Engebretsen L, LaPrade RF. Kinematic analysis of the posterior cruciate ligament, part 1: the individual and collective function of the anterolateral and posteromedial bundles. Am J Sports Med 2013; 41:2828-38. [PMID: 24064797 DOI: 10.1177/0363546513504287] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The posterior cruciate ligament (PCL) is composed of 2 functional bundles and has an essential role in knee function and stability. There is, however, a limited understanding of the role of each individual bundle through the full range of knee flexion. HYPOTHESIS Both bundles provide restraint to posterior tibial translation across a full range of knee flexion. At higher angles of knee flexion (>90°), the intact PCL also imparts significant rotational stability. STUDY DESIGN Controlled laboratory study. METHODS Twenty matched-paired, human cadaveric knees (mean age, 55.2 years; range, 51-59 years; 6 male and 4 female pairs) were used to evaluate the kinematics of an intact, anterolateral bundle (ALB) sectioned, posteromedial bundle (PMB) sectioned, and complete PCL sectioned knee. A 6 degree of freedom robotic system was used to assess knee stability with an applied 134-N posterior tibial load, 5-N·m external and internal rotation torques, 10-N·m valgus and varus torques, and a coupled 100-N posterior tibial load and 5-N external rotation torque at 0°, 15°, 30°, 45°, 60°, 75°, 90°, 105°, and 120°. RESULTS All sectioned states had significant increases compared with intact in posterior translation, internal rotation, and external rotation at all tested flexion angles, with the exception of the ALB sectioned state at 75° of flexion for external rotation. The significant increases (mean ± standard deviation) in posterior translation during a 134-N posterior tibial load at 90° of flexion were 0.9 ± 0.6 mm, 2.6 ± 1.8 mm, and 11.7 ± 4.0 mm for the PMB, ALB, and complete PCL sectioned states, respectively, compared with the intact state. The largest significant increases in internal rotation were in the PMB and complete PCL sectioned states at 105° of flexion, 1.3° ± 1.0° and 2.8° ± 2.1°, respectively. CONCLUSION Both the ALB and the PMB assume a significant role in resisting posterior tibial translation, at all flexion angles, suggesting a codominant relationship. The PCL provided a significant constraint to internal rotation beyond 90° of flexion. CLINICAL RELEVANCE This information broadens the understanding of native knee kinematics and provides a template for the evaluation of single- and double-bundle PCL reconstructions.
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Affiliation(s)
- Nicholas I Kennedy
- Robert F. LaPrade, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO 81657.
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Montgomery SR, Johnson JS, McAllister DR, Petrigliano FA. Surgical management of PCL injuries: indications, techniques, and outcomes. Curr Rev Musculoskelet Med 2013; 6:115-23. [PMID: 23430587 DOI: 10.1007/s12178-013-9162-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The ideal treatment for posterior cruciate ligament (PCL) injuries is controversial and remains an active area of orthopedic research. The indications for surgery and the ideal method of reconstruction continue to be evaluated in biomechanical and clinical studies. Recent research has provided information on the anatomy and biomechanics of the PCL, and the merits and drawbacks of the transtibial compared with the tibial inlay technique, the use of single vs double-bundle reconstruction, and different graft options for reconstruction. This review discusses important factors in the surgical treatment of PCL injuries, with attention to the most current literature on these topics.
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Affiliation(s)
- Scott R Montgomery
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA,
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A historical perspective of PCL bracing. Knee Surg Sports Traumatol Arthrosc 2013; 21:1064-70. [PMID: 22622778 DOI: 10.1007/s00167-012-2048-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 05/02/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Currently there are many functional knee braces but very few designed to treat the posterior cruciate ligament (PCL). No PCL braces have been biomechanically validated to demonstrate that they provide stability with proper force distribution to the PCL-deficient knee. The purpose of this review was to evaluate the history and current state of PCL bracing and to identify areas where further progress is required to improve patient outcomes and treatment options. METHODS A PubMed search was conducted with the terms "posterior cruciate ligament", "rehabilitation", "history", "knee", and "brace", and the relevant articles from 1967 to 2011 were analysed. A review of the current available PCL knee bracing options was performed. RESULTS Little evidence exists from the eight relevant articles to support the biomechanical efficacy of nonoperative and postoperative PCL bracing protocols. Clinical outcomes reported improvements in reducing PCL laxity with anterior directed forces to the tibia during healing following PCL tears. Biomechanics research demonstrates that during knee flexion, the PCL experiences variable tensile forces. One knee brace has been specifically designed and clinically validated to improve stability in PCL-deficient knees during rehabilitation. While available PCL braces demonstrate beneficial patient outcomes, they lack evidence validating their biomechanical effectiveness. CONCLUSIONS There is limited information evaluating the specific effectiveness of PCL knee braces. A properly designed PCL brace should apply correct anatomic joint forces that vary with the knee flexion angle and also provide adjustability to satisfy the demands of various activities. No braces are currently available with biomechanical evidence that satisfies these requirements. LEVEL OF EVIDENCE IV.
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Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc 2013; 21:1071-84. [PMID: 22484415 DOI: 10.1007/s00167-012-1970-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 03/12/2012] [Indexed: 01/22/2023]
Abstract
PURPOSE Historically, the results of posterior cruciate ligament (PCL) reconstructions are not as favourable as anterior cruciate ligament (ACL) reconstructions, and it is well recognized that nonoperative treatment and postoperative rehabilitation for PCL injuries must be altered compared to those for ACL injuries. The purpose of this article was to review current peer-reviewed PCL rehabilitation programmes and to recommend a nonoperative and postoperative programme based on basic science and published outcomes studies. METHODS To discover the current practices being used to rehabilitate PCL injuries, we conducted a search of PubMed with the terms "posterior cruciate ligament" and "rehabilitation" from 1983 to 2011. All articles within the reference lists of these articles were also examined to determine their rehabilitation programmes. RESULTS A review of peer-reviewed PCL rehabilitation protocols revealed that the treatment of PCL injuries depends on the timing and degree of the injury. Rehabilitation should focus on progressive weight bearing, preventing posterior tibial subluxation and strengthening of the quadriceps muscles. General principles of proper PCL rehabilitation, whether nonoperative or postoperative, should include early immobilization (when necessary), prone passive range of motion to prevent placing undue stress on grafts or healing tissue, and progression of rehabilitation based on biomechanical, clinical, and basic science research. CONCLUSIONS An optimal set of guidelines for the nonoperative or postoperative management of PCL injuries has not yet been defined or agreed upon. Based on the current review study, suggested guidelines are proposed. LEVEL OF EVIDENCE IV.
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Xu Z, Chen D, Shi D, Jiang Q. Case report: Osteochondral avulsion fracture of the posteromedial bundle of the PCL in knee hyperflexion. Clin Orthop Relat Res 2012; 470:3616-23. [PMID: 23054525 PMCID: PMC3492605 DOI: 10.1007/s11999-012-2632-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 09/24/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injury of the PCL of the knee in adults usually results in rupture rather than avulsion fracture and avulsions usually occur at the tibial insertion. CASE DESCRIPTION We report an avulsion of the PCL with a femoral origin in a 22-year-old man who was injured by hyperflexion of the knee and was treated with arthroscopy. There were two parts in the partial osteochondral avulsion fracture of the PCL posteromedial (PM) bundle. One part was fixed with polydioxanone suture through drill holes and the other was removed. The fracture healed after 3 months and the knee was stable. At 11 months postoperatively the patient had returned to full-time work without pain or restrictions. The Lysholm II knee score was 95 points. Physical examination showed a negative posterior drawer sign. LITERATURE REVIEW We identified four other reported cases of PCL femoral origin avulsion fractures in adults. The subjects were 20 to 25 years old in four of five reports, including our patient. Three of the five patients had involvement of only the lateral cortex of the medial femoral condyle whereas two other patients including our patient, had an osteochondral fracture. The mechanism of PCL avulsion seems to be similar to that of a PCL rupture. PURPOSES AND CLINICAL RELEVANCE The hyperflexion injury may result in injury of the PM bundle of the PCL. Our case and one other in the literature suggest such avulsions need not involve the entire PCL.
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Affiliation(s)
- Zhihong Xu
- Department of Orthopaedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008 Jiangsu PR China
| | - Dongyang Chen
- Department of Orthopaedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008 Jiangsu PR China
| | - Dongquan Shi
- Department of Orthopaedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008 Jiangsu PR China
| | - Qing Jiang
- Department of Orthopaedics, The Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008 Jiangsu PR China
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LaPrade RF, Pierce CM. Double-Bundle Posterior Cruciate Ligament Reconstruction Technique with Use of Endoscopic Femoral Graft Placement. JBJS Essent Surg Tech 2012; 2:e1. [DOI: 10.2106/jbjs.st.k.00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chandrasekaran S, Scarvell JM, Buirski G, Woods KR, Smith PN. Magnetic resonance imaging study of alteration of tibiofemoral joint articulation after posterior cruciate ligament injury. Knee 2012; 19:60-4. [PMID: 21232963 DOI: 10.1016/j.knee.2010.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 11/17/2010] [Accepted: 11/27/2010] [Indexed: 02/02/2023]
Abstract
Cadaveric studies have shown that the posterior cruciate ligament (PCL) is an important constraint to posterior translation of the tibia. Arthroscopic studies have shown that chronic PCL injuries predispose to articular cartilage lesions in the medial compartment and the patellofemoral joint. The aim of the present study was to investigate sagittal plane articulation of the tibiofemoral joint of subjects with an isolated PCL injury. Magnetic resonance was used to generate sagittal images of 10 healthy knees and 10 knees with isolated PCL injuries. The subjects performed a supine leg press against a 150N load. Images were generated at 15° intervals as the knee flexed from 0 to 90°. The tibiofemoral contact and the flexion facet centre (FFC) were measured from the posterior tibial cortex. The contact pattern and FFC was significantly more anterior in the injured knee from 45 to 90° of knee flexion in the medial compartment compared to the healthy knee. The greatest difference between the mean TFC points of both groups occurred at 75 and 90°, the difference being 4mm and 5mm respectively. The greatest difference between the mean FFC of both groups occurred at 75° of flexion, which was 3mm. There was no significant difference in the contact pattern and FFC between the injured and healthy knees in the lateral compartment. Our findings show that there is a significant difference in the medial compartment sagittal plane articulation of the tibiofemoral joint in subjects with an isolated PCL injury.
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Spiridonov SI, Slinkard NJ, LaPrade RF. Isolated and combined grade-III posterior cruciate ligament tears treated with double-bundle reconstruction with use of endoscopically placed femoral tunnels and grafts: operative technique and clinical outcomes. J Bone Joint Surg Am 2011; 93:1773-80. [PMID: 22005862 DOI: 10.2106/jbjs.j.01638] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A variety of techniques have been developed to improve clinical outcomes and objective knee stability following posterior cruciate ligament (PCL) reconstruction. Additional refinements in surgical and rehabilitation techniques are necessary for improvement of both subjective and objective outcomes. METHODS All patients studied underwent endoscopic PCL reconstruction with a double-bundle allograft. All of the allografts were placed into the femoral tunnel through a lateral arthroscopic portal, secured by an all-inside method, and were passed distally through a transtibial tunnel. Modified Cincinnati subjective and International Knee Documentation Committee (IKDC) subjective and objective outcome scores and posterior stress radiographs of the knee were made preoperatively and at the time of final follow-up. RESULTS There were a total of thirty-nine patients, including thirty-three male and six female patients, with an average age of thirty-three years. There were seven isolated PCL reconstructions and thirty-two combined reconstructions of the knee. Eight patients were not available for follow-up at a minimum of two years, leaving a cohort of thirty-one patients. Preoperative Cincinnati and IKDC subjective scores averaged 34.5 and 39.3, respectively. These scores improved significantly to 73.2 and 74.3, respectively, at an average of 2.5 years postoperatively. On posterior stress radiographs, the average posterior tibial translation of the knees was 15 mm preoperatively and improved significantly to 0.9 mm postoperatively. CONCLUSIONS Patients undergoing double-bundle PCL reconstruction with use of endoscopic placement of femoral tunnels had significant improvements in subjective and objective outcome scores and with objective knee stability.
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Affiliation(s)
- Stanislav I Spiridonov
- Department of Orthopaedic Surgery, University of Minnesota, 2515 South 7th Street, Suite R-200, Minneapolis, MN 55454, USA
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Van de Velde SK, Gill TJ, Li G. Dual fluoroscopic analysis of the posterior cruciate ligament-deficient patellofemoral joint during lunge. Med Sci Sports Exerc 2010; 41:1198-205. [PMID: 19461548 DOI: 10.1249/mss.0b013e3181981eb5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To investigate the effect of posterior cruciate ligament (PCL) deficiency on the kinematics and the cartilage contact characteristics of the patellofemoral joint during an in vivo single-leg lunge. METHODS Ten patients with an isolated PCL injury in one knee and the contralateral side intact participated in the study. Magnetic resonance and dual fluoroscopic imaging techniques were used to analyze the patellofemoral kinematics and cartilage contact of the intact and the PCL-deficient knee during a quasi-static single-leg lunge from 0 degrees to 120 degrees of flexion. RESULTS PCL deficiency significantly changed the patellofemoral kinematics between 90 degrees and 120 degrees of knee flexion (P < 0.007): an increased patellar flexion angle by 10.7 degrees on average and a decreased lateral shift (on average -1.9 mm), patellar tilt (approximately -2.7 degrees ), and valgus rotation (approximately -1.8 degrees ) were observed in the PCL-deficient knee compared with the intact contralateral joint. The changes in patellofemoral kinematics resulted in significant changes in patellofemoral cartilage contact (P < 0.007). PCL deficiency caused a distal (approximately -3.3 mm) and medial (approximately + 2.7 mm) shift of cartilage contact from 75 degrees to 120 degrees of flexion. CONCLUSION The altered tibiofemoral kinematics that were previously described in PCL deficiency resulted in changes in patellofemoral joint function at flexion angles greater than 75 degrees. This abnormal loading of the patellofemoral joint might predispose the patellofemoral cartilage to degenerative changes. Because we did not detect differences in the patellofemoral joint behavior of the intact and the PCL-deficient knee between 0 degrees and 60 degrees of flexion, rehabilitation exercises might be safely performed in this range of flexion. On the other hand, repetitive deep knee squats should be avoided in PCL-deficient patients, so as not to excessively disturb the patellofemoral cartilage contact kinematics.
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Affiliation(s)
- Samuel K Van de Velde
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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Fukagawa S, Matsuda S, Tashiro Y, Hashizume M, Iwamoto Y. Posterior displacement of the tibia increases in deep flexion of the knee. Clin Orthop Relat Res 2010; 468:1107-14. [PMID: 19847583 PMCID: PMC2835598 DOI: 10.1007/s11999-009-1118-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 09/21/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Deep knee flexion is important to proper function for some activities and in some cultures, although there are large posterior forces during high knee flexion. Most of what we know about posterior restraint and stability, however, has not been determined from deep flexion and without distinguishing motion in the medial and lateral compartments. QUESTIONS/PURPOSES We therefore evaluated (1) the difference in posterior displacement between the medial and lateral compartments at a commonly used flexion angle of 90 degrees ; (2) that of deeply flexed knees at 135 degrees ; and (3) the difference in kinematics in the medial and lateral compartments. We analyzed posterior stability in 21 normal knees using interventional open magnetic resonance imaging (MRI) system. RESULTS When manual posterior stress was applied, the posterior displacements of the tibia were 0.6 mm/2.1 mm (medial/lateral) at 90 degrees and 0.6 mm/3.6 mm at 135 degrees . The posterior aspect of the femoral medial condyle moved 7.5 mm anteriorly with knee flexion, whereas the lateral condyle moved 1.3 mm anteriorly. The contact point of the lateral compartment moved 9.2 mm posteriorly with knee flexion, whereas the contact point of the medial compartment moved 2.3 mm anteriorly. CONCLUSIONS Posterior displacement was larger in the lateral compartment at both flexion angles with manual posterior stress. As the knees flexed from 90 degrees to 135 degrees , posterior displacement became larger in the lateral compartment. CLINICAL RELEVANCE Cruciate-retaining total knee arthroplasty (TKA) or posterior cruciate ligament (PCL) reconstruction surgery should aim to achieve stability on the medial side and a few millimeters of laxity at the lateral side at 90 degrees flexion with increasing laxity only on the lateral side in deep flexion.
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Affiliation(s)
- Shingo Fukagawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Yasutaka Tashiro
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
- Department of Advanced Medicine and Innovative Technology, Kyushu University Hospital, Fukuoka, Japan
| | - Makoto Hashizume
- Department of Advanced Medicine and Innovative Technology, Kyushu University Hospital, Fukuoka, Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
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Gill TJ, Van de Velde SK, Wing DW, Oh LS, Hosseini A, Li G. Tibiofemoral and patellofemoral kinematics after reconstruction of an isolated posterior cruciate ligament injury: in vivo analysis during lunge. Am J Sports Med 2009; 37:2377-85. [PMID: 19726621 PMCID: PMC3832057 DOI: 10.1177/0363546509341829] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The actual in vivo tibiofemoral and patellofemoral kinematics of the posterior cruciate ligament (PCL)-reconstructed knee joint are unknown. HYPOTHESIS Current single-bundle PCL reconstruction is unable to correct the abnormal tibiofemoral and patellofemoral kinematics caused by rupture of the ligament. STUDY DESIGN Controlled laboratory study/case series; Level of evidence, 4. METHODS Seven patients with an isolated PCL injury in 1 knee and the contralateral side intact were included in the study. Magnetic resonance and dual fluoroscopic imaging techniques were used to compare the tibiofemoral and patellofemoral kinematics between the intact contralateral (control group), PCL-deficient, and PCL-reconstructed knee during physiologic loading with a single-legged lunge. Data were collected preoperatively and 2 years after single-bundle reconstruction. RESULTS The PCL reconstruction reduced the abnormal posterior tibial translation in PCL-deficient knees to levels not significantly different from those of the intact knee. Posterior cruciate ligament deficiency resulted in an increased lateral tibial translation between 75 degrees and 120 degrees of flexion, and reconstruction was unable to restore these values to normal. No differences were detected among the groups in varus-valgus and internal-external rotation. The PCL reconstruction reduced the increased patellar flexion of PCL-deficient knees between 90 degrees and 120 degrees of knee flexion and the lateral shift at 120 degrees . The abnormal patellar rotation and tilt seen in PCL deficiency at flexion angles of 75 degrees and greater persisted after reconstruction. CONCLUSION Single-bundle PCL reconstruction was successful in restoring normal anteroposterior translation of the tibia, as well as the patellar flexion and shift. However, single-bundle PCL reconstruction was unable to achieve the same success in mediolateral translation of the tibia or in the patellar rotation and tilt. CLINICAL RELEVANCE The persistent abnormal mediolateral translation of the tibia, as well as decreased patellar rotation and tilt, provide a possible explanation for the development of cartilage degeneration after reconstruction of an isolated PCL injury.
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Affiliation(s)
| | | | | | | | | | - Guoan Li
- Address correspondence to Guoan Li, PhD, Bioengineering Laboratory, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street—GRJ 1215, Boston, MA 02114 ()
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Heinzelmann AD, Barrett GR. Posterior Cruciate Ligament Reconstruction: Achilles Tendon Allograft, Double Bundle. Clin Sports Med 2009; 28:245-57, viii. [DOI: 10.1016/j.csm.2008.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Battaglia MJ, Lenhoff MW, Ehteshami JR, Lyman S, Provencher MT, Wickiewicz TL, Warren RF. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model. Am J Sports Med 2009; 37:305-11. [PMID: 19098154 DOI: 10.1177/0363546508324969] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Numerous studies have documented the effect of complete medial collateral ligament injury on anterior cruciate ligament loads; few have addressed how partial medial collateral ligament disruption affects knee kinematics. PURPOSE To determine knee kinematics and subsequent change in anterior cruciate ligament load in a partial and complete medial collateral ligament injury model. STUDY DESIGN Controlled laboratory study. METHODS Ten human cadaveric knees were sequentially tested by a robot with the medial collateral ligament intact, in a partial injury model, and in a complete injury model with a universal force-moment sensor measuring system. Tibial translation, rotation, and anterior cruciate ligament load were measured under 3 conditions: anterior load (125 N), valgus load (10 N x m), and internal-external rotation torque (4 N x m; all at 0 degrees and 30 degrees of flexion). RESULTS Anterior and posterior translation did not statistically increase with a partial or complete medial collateral ligament injury at 0 degrees and 30 degrees of flexion. In response to a 125 N anterior load, at 0 degrees , the anterior cruciate ligament load increased 8.7% (from 99.5 to 108.2 N; P = .006) in the partial injury and 18.3% (117.7 N; P < .001) in the complete injury; at 30 degrees , anterior cruciate ligament load was increased 12.3% (from 101.7 to 114.2 N; P = .001) in the partial injury and 20.6% (122.7 N; P < .001) in the complete injury. In response to valgus torque (10 N x m) at 30 degrees , anterior cruciate ligament load was increased 55.3% (30.4 to 47.2 N; P = .044) in the partial injury model and 185% (86.8 N; P = .001) in the complete injury model. In response to internal rotation torque (4 N.m) at 30 degrees , anterior cruciate ligament load was increased 29.3% (27.6 to 35.7 N; P = .001) in the partial injury model and 65.2% (45.6 N; P < .001) in the complete injury model. The amount of internal rotation at 30 degrees of flexion was significantly increased in the complete injury model (22.8 degrees ) versus the intact state (19.5 degrees ; P < .001). CONCLUSION Partial and complete medial collateral ligament tears significantly increased the load on the anterior cruciate ligament. In a partial tear, the resultant load on the anterior cruciate ligament was increased at 30 degrees of flexion and with valgus load and internal rotation torque. CLINICAL RELEVANCE Patients may need to be protected from valgus and internal rotation forces after anterior cruciate ligament reconstruction in the setting of a concomitant partial medial collateral ligament tear. This information may help clinicians understand the importance of partial injuries of the medial collateral ligament with a combined anterior cruciate ligament injury complex.
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Affiliation(s)
- Michael J Battaglia
- Shoulder and Sports Orthopedic Surgery, United States Naval Academy, 250 Wood Road, Annapolis, MD 21402, USA.
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Van de Velde SK, Bingham JT, Gill TJ, Li G. Analysis of tibiofemoral cartilage deformation in the posterior cruciate ligament-deficient knee. J Bone Joint Surg Am 2009; 91:167-75. [PMID: 19122092 PMCID: PMC2663325 DOI: 10.2106/jbjs.h.00177] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Degeneration of the tibiofemoral articular cartilage often develops in patients with posterior cruciate ligament deficiency, yet little research has focused on the etiology of this specific type of cartilage degeneration. In this study, we hypothesized that posterior cruciate ligament deficiency changes the location and magnitude of cartilage deformation in the tibiofemoral joint. METHODS Fourteen patients with a posterior cruciate ligament injury in one knee and the contralateral side intact participated in the study. First, both knees were imaged with use of a specific magnetic resonance imaging sequence to create three-dimensional knee models of the surfaces of the bone and cartilage. Next, each patient performed a single leg lunge as images were recorded with a dual fluoroscopic system at 0 degrees, 30 degrees, 60 degrees, 75 degrees, 90 degrees, 105 degrees, and 120 degrees of knee flexion. Finally, the three-dimensional knee models and fluoroscopic images were used to reproduce the in vivo knee position at each flexion angle with use of a previously described image-matching method. With use of these series of knee models, the location and magnitude of peak tibiofemoral cartilage deformation at each flexion angle were compared between the intact contralateral and posterior cruciate ligament-deficient knees. RESULTS In the medial compartment of the posterior cruciate ligament-deficient knees, the location and magnitude of peak cartilage deformation were significantly changed, compared with those in the intact contralateral knees, between 75 degrees and 120 degrees of flexion, with a more anterior and medial location of peak cartilage deformation on the tibial plateau as well as increased deformation of the cartilage. In the lateral compartment, no significant differences in the location or magnitude of peak cartilage deformation were found between the intact and posterior cruciate ligament-deficient knees. CONCLUSIONS The altered kinematics associated with posterior cruciate ligament deficiency resulted in a shift of the tibiofemoral contact location and an increase in cartilage deformation in the medial compartment beyond 75 degrees of knee flexion. The magnitude of the medial contact shift in the posterior cruciate ligament-deficient knee was on the same order as that of the anterior contact shift.
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Affiliation(s)
- Samuel K. Van de Velde
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, GRJ 1215, Boston, MA 02114. E-mail address for G. Li:
| | - Jeffrey T. Bingham
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, GRJ 1215, Boston, MA 02114. E-mail address for G. Li:
| | - Thomas J. Gill
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, GRJ 1215, Boston, MA 02114. E-mail address for G. Li:
| | - Guoan Li
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, 55 Fruit Street, GRJ 1215, Boston, MA 02114. E-mail address for G. Li:
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Mauro CS, Sekiya JK, Stabile KJ, Haemmerle MJ, Harner CD. Double-bundle PCL and posterolateral corner reconstruction components are codominant. Clin Orthop Relat Res 2008; 466:2247-54. [PMID: 18523834 PMCID: PMC2493001 DOI: 10.1007/s11999-008-0319-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 05/12/2008] [Indexed: 01/31/2023]
Abstract
A more complete biomechanical understanding of a combined posterior cruciate ligament and posterolateral corner knee reconstruction may help surgeons develop uniformly accepted clinical surgical techniques that restore normal anatomy and protect the knee from premature arthritic changes. We identified the in situ force patterns of the individual components of a combined double-bundle posterior cruciate ligament and posterolateral corner knee reconstruction. We tested 10 human cadaveric knees using a robotic testing system by sequentially cutting and reconstructing the posterior cruciate ligament and posterolateral corner. The knees were subjected to a 134-N posterior tibial load and 5-Nm external tibial torque. The posterior cruciate ligament was reconstructed with a double-bundle technique. The posterolateral corner reconstruction included reattaching the popliteus tendon to its femoral origin and reconstructing the popliteofibular ligament. The in situ forces in the anterolateral bundle were greater in the posterolateral corner-deficient state than in the posterolateral corner-reconstructed state at 30 degrees under the posterior tibial load and at 90 degrees under the external tibial torque. We observed no differences in the in situ forces between the anterolateral and posteromedial bundles under any loading condition. The popliteus tendon and popliteofibular ligament had similar in situ forces at all flexion angles. The data suggest the two bundles protect each other by functioning in a load-sharing, codominant fashion, with no component dominating at any flexion angle. We believe the findings support reconstructing both posterior cruciate ligament bundles and both posterolateral corner components.
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Affiliation(s)
- Craig S. Mauro
- Department of Orthopaedic Surgery, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203 USA
| | - Jon K. Sekiya
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI USA
| | - Kathryne J. Stabile
- Department of Orthopaedic Surgery, Wake Forest University, Winston-Salem, NC USA
| | - Marcus J. Haemmerle
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI USA
| | - Christopher D. Harner
- Department of Orthopaedic Surgery, University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203 USA
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Apsingi S, Nguyen T, Bull AMJ, Unwin A, Deehan DJ, Amis AA. Control of laxity in knees with combined posterior cruciate ligament and posterolateral corner deficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction combined with modified Larson posterolateral corner reconstruction. Am J Sports Med 2008; 36:487-94. [PMID: 18230868 DOI: 10.1177/0363546508314415] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although many posterior cruciate ligament (PCL) injuries are in combination with posterolateral corner (PLC) injuries, there has been little research on combined injury reconstruction; the literature includes differing recommendations. HYPOTHESIS Combined PCL plus PLC reconstruction corrects the abnormal posterior translation, varus, and external rotation laxities caused by combined PCL plus PLC deficiency. Furthermore, double-bundle PCL plus PLC reconstruction restores laxity closer to normal than single-bundle PCL plus PLC reconstruction. STUDY DESIGN Controlled laboratory study. METHODS Cadaveric knee kinematics were measured electromagnetically in 9 knees with posterior drawer, external rotation, and varus rotation loads applied at sequential stages: intact, PCL-deficient, PCL plus PLC-deficient, double-bundle PCL plus modified Larson PLC reconstruction, and single-bundle PCL plus modified Larson PLC reconstruction. Each graft was tensioned using a laxity-matching protocol. RESULTS There was no significant difference between single-bundle and double-bundle PCL reconstruction, in combination with the modified Larson reconstruction, at any angle of flexion. Both combined reconstructions restored posterior drawer, external rotation, and varus laxity so that they did not differ significantly from normal. CONCLUSION In combined PCL plus PLC deficiency, combined PCL plus PLC reconstruction restored all major laxity limits to normal across the range of knee flexion examined. Double-bundle PCL reconstruction was not better than single-bundle reconstruction in this context. CLINICAL RELEVANCE The added complexity of double-bundle reconstruction does not seem to be justified by these results. In combined PCL plus PLC-deficient knees, combined single-bundle PCL plus modified Larson PLC reconstruction was sufficient to restore posterior drawer, external rotation, and varus laxity to normal.
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Li G, Papannagari R, Li M, Bingham J, Nha KW, Allred D, Gill T. Effect of posterior cruciate ligament deficiency on in vivo translation and rotation of the knee during weightbearing flexion. Am J Sports Med 2008; 36:474-9. [PMID: 18057390 DOI: 10.1177/0363546507310075] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effect of posterior cruciate ligament (PCL) deficiency on 6 degrees of freedom in vivo knee-joint kinematics is unclear. HYPOTHESIS In addition to constraining anterior-posterior translation, the PCL also functions to constrain the medial-lateral translation and rotation of the knee during weightbearing flexion of the knee. STUDY DESIGN Controlled laboratory study. METHODS Eight patients with a PCL injury in 1 knee and the other intact were scanned with magnetic resonance imaging, and 3-dimensional models of the femur and tibia were created for both knees. Each knee was imaged during quasistatic weight-bearing flexion (from 0 degrees to 105 degrees ) using a dual-orthogonal fluoroscopic system. The translation and rotation of the PCL-deficient knee were compared with the intact contralateral control. RESULTS Posterior cruciate ligament deficiency caused an increase in posterior tibial translation beyond 30 degrees of flexion compared with the intact contralateral knees. At 90 degrees of flexion, PCL deficiency increased posterior tibial translation by 3.5 mm (P < .05). In the medial-lateral direction, PCL deficiency resulted in a 1.1 mm increase in lateral tibial translation at 90 degrees of flexion (P < .05). With regard to rotation, PCL deficiency caused a significantly lower varus rotation (on average, 0.6 degrees lower) at 90 degrees of flexion. Posterior cruciate ligament deficiency caused a decreased internal tibial rotation throughout the range of flexion, but no significant difference was detected. CONCLUSIONS This study quantitatively describes the effect of PCL injury on 6 degrees of freedom kinematics of the knee during quasistatic weightbearing flexion. Using the intact contralateral side as a control, we found that PCL injuries not only affect anterior-posterior tibial translation but also medial-lateral translation and rotation of the knee. CLINICAL RELEVANCE These data provide baseline knowledge of the in vivo kinematics of the knee after PCL injury. Surgical reconstruction of the injured PCL, either using single-bundle or double-bundle technique, should not only focus on restoration of posterior stability of the knee but also the medial-lateral stability as well as the rotational stability. These findings may help to explain the long-term degenerative changes seen in PCL-deficient knees.
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Affiliation(s)
- Guoan Li
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Covey DC, Sapega AA, Riffenburgh RH. The effects of sequential sectioning of defined posterior cruciate ligament fiber regions on translational knee motion. Am J Sports Med 2008; 36:480-6. [PMID: 18055918 DOI: 10.1177/0363546507311097] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent studies have shown that the posterior cruciate ligament (PCL) is composed of a continuum of fiber regions that display characteristic mechanical behavior under different motion and loading conditions. HYPOTHESIS The anterior, central, and posterior fiber regions of the PCL differentially contribute to control of posterior translation of the tibia. STUDY DESIGN Controlled laboratory study. METHODS Nine intact, fresh-frozen cadaveric knees were instrumented with excursion wires implanted within the anterior, central, and posterior fiber regions of the PCL. In groups of 3, patterns of incremental posterior tibial translation using a 74-N posterior force were analyzed as a function of the variable linear separation distance between tibial and femoral fiber region attachment sites during posterior drawer testing at knee flexion angles of 20 degrees and 90 degrees before and after sequential fiber region section. RESULTS At 20 degrees of knee flexion, there was no statistical difference in the relatively small amount of posterior tibial translation, regardless of whether the anterior, central, or posterior fibers were alone transected (P = .350). At 90 degrees of knee flexion, whether the posterior fibers were cut first, second, or third (order of section), the incremental difference in posterior tibial translation this produced was significantly different (P = .039). For the fiber regions combined, the third fiber region section resulted in a significantly larger incremental translation than did either the first or second section with the knee flexed 90 degrees (P = .001). After transection of all fiber regions, significantly more total posterior tibial translation occurred at 90 degrees versus 20 degrees of flexion (P = .002). CONCLUSIONS This study shows that fiber regions within the PCL have unique characteristics and behave differently in response to posterior drawer forces. CLINICAL RELEVANCE This study provides additional information on the complex mechanical behavior of the PCL and suggests that some partial tears (ie, those involving 1 or 2 fiber regions) may only result in minimal posterior translation during drawer testing at 90 degrees .
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Affiliation(s)
- D C Covey
- Department of Orthopaedic Surgery, Naval Medical Center, 34800 Bob Wilson Drive, San Diego, CA 92134-1112, USA.
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Apsingi S, Nguyen T, Bull AMJ, Unwin A, Deehan DJ, Amis AA. The role of PCL reconstruction in knees with combined PCL and posterolateral corner deficiency. Knee Surg Sports Traumatol Arthrosc 2008; 16:104-11. [PMID: 18060383 DOI: 10.1007/s00167-007-0444-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 10/22/2007] [Indexed: 12/20/2022]
Abstract
Although many PCL injuries are in combination with posterolateral corner (PLC) injuries, there has been little work done on combined injury reconstruction; the literature includes differing recommendations. It was hypothesised that a double-bundle PCL reconstruction would restore both posterior drawer and external rotation laxities closer to normal than an isolated single-bundle reconstruction in combined PCL plus PLC-deficient knees. However, it was also hypothesised that an isolated PCL reconstruction would still leave abnormal rotation laxity. In this controlled laboratory study, cadaver knee kinematics were measured electromagnetically with posterior drawer, external rotation, varus rotation loads applied, at sequential stages: intact; PCL-deficient; PCL plus PLC-deficient; double-bundle PCL reconstruction; single-bundle PCL reconstruction. The grafts were tensed using a posterior drawer laxity matching protocol. There was no significant difference between single- and double-bundle PCL reconstructions at any angle of flexion: both reconstructions restored posterior drawer to normal; neither reconstruction restored external rotation or varus laxity to normal. We concluded that, in combined PCL plus PLC deficiency, isolated PCL reconstruction only controls tibial posterior drawer, but is not sufficient to restore rotational laxity to normal. Double-bundle PCL reconstruction was not better than single-bundle, so the added complexity of double-bundle reconstruction does not seem to be justified by these results.
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Affiliation(s)
- S Apsingi
- Freeman Hospital, Newcastle, NE7 7DN, UK
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Amiri S, Cooke D, Kim IY, Wyss U. Mechanics of the passive knee joint. Part 2: interaction between the ligaments and the articular surfaces in guiding the joint motion. Proc Inst Mech Eng H 2008; 221:821-32. [PMID: 18161242 DOI: 10.1243/09544119jeim181] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to examine how the interaction between ligament tensions and contact forces guides the knee joint through its specific pattern of passive motion. A computer model was built based on cadaver data. The passive motion and the ligament lengthening and force patterns predicted by the model were verified with data from the literature. The contribution of each ligament and contact force was measured in terms of the rotational moment that it produced about the tibial medial plateau and the anterior-posterior (AP) force that it exerted on the tibia. The high tension of the anterior cruciate ligament (ACL) and the geometric constraints of the anterior horns of the menisci were found to be key features that stabilized the knee at full extension. The mutual effect of the cruciates was found as the reason for the screw-home mechanism at early flexion. Past 300, the AP component of contact force on the convex geometry of the lateral tibial plateau and tension of the lateral collateral ligament (LCL) were identified as elements that control the joint motion. From 60 degrees to 90 degrees, reduction in the tension of the ACL was determined as a reason for continuation of the tibial anterior translation. From 90 degrees to 120 degrees, increase in the tension of the posterior cruciate ligament and the AP component of the contact force on the convex geometry of the lateral tibial plateau pushed the tibia more anteriorly. This anterior translation was limited by the constraining effects of the ACL tension and the AP component of the contact force on the medial meniscus. The important guiding role observed for the LCL suggests that it should not be overlooked in knee models.
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Affiliation(s)
- S Amiri
- Department of Mechanical and Materials Engineering, Queen's University, 130 Stuart St, Kingston, Ontario, K7L 3N6, Canada.
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