Skip to main content

Advertisement

SpringerLink
Log in

Bicruciate lesion biomechanics, Part 1—Diagnosis: translations over 15 mm at 90° of knee flexion are indicative of a complete tear

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Understanding the pathomechanics of a bicruciate injury (BI) is critical for its correct diagnosis and treatment. The purpose of this biomechanical study aims to quantify the effects of sequential sectioning of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) bundles on knee laxity.

Methods

Twelve cadaveric knees (six matched pairs) were used. Knee laxity measurements consisted of neutral tibial position, anterior–posterior translation, internal–external rotation, and varus–valgus angulation in different conditions: intact, ACL cut, incomplete BI (divided into two groups: anterolateral (AL) bundle intact or posteromedial (PM) bundle intact) and complete bicruciate tear. Data were collected using a Microscribe system at 0°, 30°, 60°, and 90° of knee flexion.

Results

In comparison to the intact knees, incomplete BI and complete BI showed a significant increase of total antero-posterior tibial translation. The largest significant increase was observed at 90° of flexion after a complete bicruciate resection (p < 0.001). A threshold difference greater than 15 mm from the intact could be used to identify a complete BI from an incomplete BI evaluating the total antero-posterior translation at 90°. All sectioned states had significant increases compared with the intact condition in internal–external rotation and varus–valgus stability at all tested flexion angles.

Conclusion

Both incomplete and complete BI led to an important AP translation instability at all angles; however, full extension was the most stable position at all injured models. Total antero-posterior translation at 90° of knee flexion over 15 mm, in comparison to the intact condition, was indicative of a complete BI. Since the appropriate assessment of a combined ACL and PCL lesion remains a challenge, this study intends to assist its diagnosis. As BI’s main antero-posterior instability occurred at 90°, a total antero-posterior drawer test is proposed to evaluate BI in the clinical setting. Total antero-posterior translation at 90° > 15 mm, in comparison to the intact condition or the contra-lateral non-injured knee, can be used to identify a complete from an incomplete BI.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR (2003) Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 11:271–281

    Article  CAS  PubMed  Google Scholar 

  2. Amis AA, Gupte CM, Bull AM, Edwards A (2006) Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 14:257–263

    Article  CAS  PubMed  Google Scholar 

  3. Anderson CJ, Ziegler CG, Wijdicks CA, Engebretsen L, LaPrade RF (2012) Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the posterior cruciate ligament. J Bone Jt Surg Am 94:1936–1945

    Article  Google Scholar 

  4. Boisgard S, Versier G, Descamps S, Lustig S, Trojani C, Rosset P et al (2009) Bicruciate ligament lesions and dislocation of the knee: mechanisms and classification. Orthop Traumatol Surg Res 95:627–631

    Article  CAS  PubMed  Google Scholar 

  5. Butler DL, Noyes FR, Grood ES (1980) Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study. J Bone Joint Surg Am 62:259–270

    Article  CAS  PubMed  Google Scholar 

  6. Covey DC, Sapega AA, Riffenburgh RH (2008) The effects of sequential sectioning of defined posterior cruciate ligament fiber regions on translational knee motion. Am J Sports Med 36:480–486

    Article  CAS  PubMed  Google Scholar 

  7. Csintalan RP, Ehsan A, McGarry MH, Fithian DF, Lee TQ (2006) Biomechanical and anatomical effects of an external rotational torque applied to the knee: a cadaveric study. Am J Sports Med 34:1623–1629

    Article  PubMed  Google Scholar 

  8. Denti M, Tornese D, Melegati G, Schonhuber H, Quaglia A, Volpi P (2015) Combined chronic anterior cruciate ligament and posterior cruciate ligament reconstruction: functional and clinical results. Knee Surg Sports Traumatol Arthrosc 23:2853–2858

    Article  PubMed  Google Scholar 

  9. Fornalski S, McGarry MH, Csintalan RP, Fithian DC, Lee TQ (2008) Biomechanical and anatomical assessment after knee hyperextension injury. Am J Sports Med 36:80–84

    Article  PubMed  Google Scholar 

  10. Garavaglia G, Lubbeke A, Dubois-Ferriere V, Suva D, Fritschy D, Menetrey J (2007) Accuracy of stress radiography techniques in grading isolated and combined posterior knee injuries: a cadaveric study. Am J Sports Med 35:2051–2056

    Article  PubMed  Google Scholar 

  11. Hewett TE, Noyes FR, Lee MD (1997) Diagnosis of complete and partial posterior cruciate ligament ruptures. Stress radiography compared with KT-1000 arthrometer and posterior drawer testing. Am J Sports Med 25:648–655

    Article  CAS  PubMed  Google Scholar 

  12. Ishigooka H, Campbell ST, Quigley RJ, McGarry MH, Chen YJ, Gupta A et al (2016) Anatomic posterolateral corner reconstruction using a fibula cross-tunnel technique: a cadaveric biomechanical study. Arthroscopy 32:2300–2307

    Article  PubMed  Google Scholar 

  13. Kennedy NI, Wijdicks CA, Goldsmith MT, Michalski MP, Devitt BM, Aroen A et al (2013) Kinematic analysis of the posterior cruciate ligament, part 1: the individual and collective function of the anterolateral and posteromedial bundles. Am J Sports Med 41:2828–2838

    Article  PubMed  Google Scholar 

  14. Kim SJ, Kim SH, Jung M, Kim JM, Lee SW (2015) Does sequence of graft tensioning affect outcomes in combined anterior and posterior cruciate ligament reconstructions? Clin Orthop Relat Res 473:235–243

    Article  PubMed  Google Scholar 

  15. Lee TQ, Yang BY, Sandusky MD, McMahon PJ (2001) The effects of tibial rotation on the patellofemoral joint: assessment of the changes in in situ strain in the peripatellar retinaculum and the patellofemoral contact pressures and areas. J Rehabil Res Dev 38:463–469

    CAS  PubMed  Google Scholar 

  16. Lee YS, Lee TQ (2010) Specimen-specific method for quantifying glenohumeral joint kinematics. Ann Biomed Eng 38:3226–3236

    Article  PubMed  PubMed Central  Google Scholar 

  17. Ma CB, Kanamori A, Vogrin TM, Woo SL, Harner CD (2003) Measurement of posterior tibial translation in the posterior cruciate ligament-reconstructed knee: significance of the shift in the reference position. Am J Sports Med 31:843–848

    Article  PubMed  Google Scholar 

  18. Noyes FR, Stowers SF, Grood ES, Cummings J, VanGinkel LA (1993) Posterior subluxations of the medial and lateral tibiofemoral compartments. An in vitro ligament sectioning study in cadaveric knees. Am J Sports Med 21:407–414

    Article  CAS  PubMed  Google Scholar 

  19. Petrigliano FA, McAllister DR (2006) Isolated posterior cruciate ligament injuries of the knee. Sports Med Arthrosc 14:206–212

    Article  PubMed  Google Scholar 

  20. Piontek T, Ciemniewska-Gorzela K, Szulc A, Naczk J, Wardak M, Trzaska T et al (2013) Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction with autologous hamstring grafts-isokinetic assessment with control group. PLoS One 8:e82462

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ (2002) Fixed posterior subluxation in posterior cruciate ligament-deficient knees: diagnosis and treatment of a new clinical sign. Am J Sports Med 30:32–38

    Article  PubMed  Google Scholar 

  22. Thaunat M, Clowez G, Murphy CG, Desseaux A, Guimaraes T, Fayard JM et al (2017) All-inside bicruciate ligament reconstruction technique: a focus on graft tensioning sequence. Arthrosc Tech 6:e655-e660

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

This study was financially supported by São Paulo Research Foundation (FAPESP) grant number 2015/10317-7. Franciozi CE received post-doctoral scholarship from FAPESP supporting his scientific activities at the University of Southern California during 2015–2016, grant number 2015/08952-6. Carvalho RT received financial support from FAPESP while performing his Ph.D. activities at University of Southern California during 2016. The authors would like to thank Arthrex for the surgical instruments and material supply, and FAPESP for the financial support. The human cadaveric specimens were obtained through the University of California, Irvine Willed Body Program. Also, the authors would like to thank Andrea Moon, Felipe Huizar, Mike Shroder, Roseli Paschoa, and Leonardo A. Ramos. Without the help, support, orientation and enthusiasm of all aforementioned people, this work would not be possible.

Funding

This study was funded by São Paulo Research Foundation (FAPESP) grant number 2015/10317-7. Franciozi CE received post-doctoral scholarship from FAPESP supporting his scientific activities at the University of Southern California during 2015-2016, grant number 2015/08952-6. Carvalho RT received financial support from FAPESP while performing his Ph.D. activities at University of Southern California during 2016.

Author information

Authors and Affiliations

  1. Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, SP, Brazil

    Rogério Teixeira de Carvalho, Carlos Eduardo Franciozi, Sheila Jean McNeill Ingham & Rene Jorge Abdalla

  2. Hospital Israelita Albert Einstein, São Paulo, SP, Brazil

    Rogério Teixeira de Carvalho & Carlos Eduardo Franciozi

  3. Knee Institute, Hospital do Coração (HCor), São Paulo, SP, Brazil

    Carlos Eduardo Franciozi, Sheila Jean McNeill Ingham & Rene Jorge Abdalla

  4. Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan

    Yasuo Itami

  5. Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, CA, USA

    Michelle H. McGarry & Thay Q. Lee

  6. AACD, São Paulo, SP, Brazil

    Sheila Jean McNeill Ingham

  7. Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    James Eugene Tibone

  8. Department of Orthopaedic Surgery, University of California at Irvine, Irvine, CA, USA

    Thay Q. Lee

Authors
  1. Rogério Teixeira de Carvalho
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Carlos Eduardo Franciozi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yasuo Itami
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michelle H. McGarry
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sheila Jean McNeill Ingham
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rene Jorge Abdalla
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. James Eugene Tibone
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Thay Q. Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carlos Eduardo Franciozi.

Ethics declarations

Conflict of interest

Carlos Eduardo Franciozi and Rene Jorge Abdalla received fees for speaking or for organizing an educational program and fee for consulting from Smith & Nephew in the past five years, not related to this study. James Eugene Tibone acts as a consultant for Arthrex but do not receive any money from them, not any related to this study. The remaining authors declare no conflict of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. This study was approved by The Federal University of São Paulo—UNIFESP—Institutional Review Board, number of Ethical Committee Approval: 45827413.5.0000.5505.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 41 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

de Carvalho, R.T., Franciozi, C.E., Itami, Y. et al. Bicruciate lesion biomechanics, Part 1—Diagnosis: translations over 15 mm at 90° of knee flexion are indicative of a complete tear. Knee Surg Sports Traumatol Arthrosc 27, 2927–2935 (2019). https://doi.org/10.1007/s00167-018-5011-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-018-5011-6

Keywords

Search

Navigation