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Anatomic is better than isometric posterior cruciate ligament tunnel placement based upon in vivo simulation

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To elucidate the effects of various tibial and femoral attachment locations on the theoretical length changes and isometry of PCL grafts in healthy knees during in vivo weightbearing motion.

Methods

The intact knees of 14 patients were imaged using a combined magnetic resonance and dual fluoroscopic imaging technique while the patient performed a quasi-static lunge (0°–120° of flexion). The theoretical end-to-end distances of the 3-dimensional wrapping paths between 165 femoral attachments, including the anatomic anterolateral bundle (ALB), central attachment and posteromedial bundle (PMB) of the PCL, connected to an anterolateral, central, and posteromedial tibial attachment were simulated and measured. A descriptive heatmap was created to demonstrate the length changes on the medial condyle and formal comparisons were made between the length changes of the anatomic PCL and most isometric grafts.

Results

The most isometric graft, with approximately 3% length change between 0° and 120° of flexion, was located proximal to the anatomic femoral PCL attachments. Grafts with femoral attachments proximal to the isometric zone decreased in length with increasing flexion angles, whereas grafts with more distal attachments increased in length with increasing flexion angles. The ALB and central single-bundle graft demonstrated a significant elongation from 0° to 120° of flexion (p < 0.001). The PMB decreased in length between 0° and 60° of flexion after which the bundle increased in length to its maximum length at 120° (p < 0.001). No significant differences in length changes were found between either the ALB or PMB and the central graft, and between the ALB and PMB at flexion angles ≥ 60° (n.s.).

Conclusions

The most isometric attachment was proximal to the anatomic PCL footprint and resulted in non-physiological length changes. Moving the femoral attachment locations of the PCL significantly affected length change patterns, whereas moving the tibia locations did not. The importance of anatomically positioned (i.e., distal to the isometric area) femoral PCL reconstruction locations to replicate physiological length changes is highlighted. These data can be used to optimize tunnel positioning in either single- or double-bundle and primary or revision PCL reconstruction cases.

Level of evidence

IV.

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Funding

This work was supported by the National Institutes of Health (NIH) Grant R-01 AR055612.

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Authors and Affiliations

  1. Bioengineering Laboratory, Newton-Wellesley Hospital, Newton, MA, 02462, USA

    Willem A. Kernkamp, Axel J. T. Jens, Nathan H. Varady & Guoan Li

  2. Sports Medicine Center, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA

    Willem A. Kernkamp, Nathan H. Varady & Peter D. Asnis

  3. Focus Clinic Orthopedic Surgery, Haaglanden Medical Center, The Hague, The Netherlands

    Axel J. T. Jens & Ewoud R. A. van Arkel

  4. Orthopedic Surgery, Leiden University Medical Center, Leiden, The Netherlands

    Willem A. Kernkamp & Rob G. H. H. Nelissen

  5. The Steadman Clinic, Vail, CO, USA

    Robert F. LaPrade

  6. Division of Pediatric Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada

    Samuel K. Van de Velde

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  1. Willem A. Kernkamp
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  2. Axel J. T. Jens
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Contributions

WAK: Conception and design of the work, acquisition, analysis and interpretation of data, drafting the work, revising the work critically for important intellectual content, final approval of the version to be published. AJTJ: Conception and design of the work, acquisition of data, revising the work critically for important intellectual content, final approval of the version to be published. NHV: Analysis and interpretation of data, revising the work critically for important intellectual content, final approval of the version to be published. ERAA: Conception and design of the work, acquisition, interpretation of data, revising the work critically for important intellectual content, final approval of the version to be published. RGHHN: Conception and design of the work, acquisition, interpretation of data, revising the work critically for important intellectual content, final approval of the version to be published. PDA: Conception and design of the work, interpretation of data, revising the work critically for important intellectual content, final approval of the version to be published. RFL: Conception and design of the work, interpretation of data, revising the work critically for important intellectual content, final approval of the version to be published. SKV: Conception and design of the work, and interpretation of data for the work, revising the work critically for important intellectual content, final approval of the version to be published. GL: Conception and design of the work, interpretation of data for the work, revising the work critically for important intellectual content, final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Guoan Li.

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Conflict of interest

No conflicts of interest related to the submitted work.

Ethical approval

Study protocol was approved by the Partners Human Research Committee (Protocol #: 2003P000337/PHS).

Electronic supplementary material

Below is the link to the electronic supplementary material.

167_2018_5233_MOESM1_ESM.mov

Lateral view of a 3D femur model in 90° of flexion, with the quadrant applied as described by Bernard et al [5]. The “heat map” illustrates the normalized graft length changes (relative to their length at 60° of flexion, i.e., zero point) of the 165 theoretical grafts when connected to the central tibial attachment for the intact knees during the quasi-static lunge (0°–120° of flexion). Attachments located proximal to the isometric zone resulted in decreased graft lengths with increasing flexion angles, whereas distal grafts increased in length with increasing flexion angles. Dashed lines show the outline of the anatomical posterior cruciate ligament footprint. The black x on the femur shows the center of the anterolateral bundle; the black dot shows the center of the posteromedial bundle (MOV 5316 KB)

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Kernkamp, W.A., Jens, A.J.T., Varady, N.H. et al. Anatomic is better than isometric posterior cruciate ligament tunnel placement based upon in vivo simulation. Knee Surg Sports Traumatol Arthrosc 27, 2440–2449 (2019). https://doi.org/10.1007/s00167-018-5233-7

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