Skip to main content
SpringerLink
Log in

The Medial structures of the knee have a significant contribution to posteromedial rotational laxity control in the PCL-deficient knee

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

Abstract

Purpose

Various reconstruction techniques have been employed to restore normal kinematics to PCL-deficient knees; however, studies show that failure rates are still high. Damage to secondary ligamentous stabilizers of the joint, which commonly occurs concurrently with PCL injuries, may contribute to these failures. The main objective of this study was to quantify the biomechanical contributions of the deep medial collateral ligament (dMCL) and posterior oblique ligament (POL) in stabilizing the PCL-deficient knee, using a joint motion simulator.

Methods

Eight cadaveric knees underwent biomechanical analysis of posteromedial stability and rotatory laxity using an AMTI VIVO joint motion simulator. Combined posterior force (100 N) and internal torque (5 Nm) loads, followed by pure internal/external torques (± 5 Nm), were applied at 0, 30, 60 and 90° of flexion. The specimens were tested in the intact state, followed by sequential sectioning of the PCL, dMCL, POL and sMCL. The order of sectioning of the dMCL and POL was randomized, providing n = 4 for each cutting sequence. Changes in posteromedial displacements and rotatory laxities were measured, as were the biomechanical contributions of the dMCL, POL and sMCL in resisting these loads in a PCL-deficient knee.

Results

Overall, it was observed that POL transection caused increased posteromedial displacements and internal rotations in extension, whereas dMCL transection had less of an effect in extension and more of an effect in flexion. Although statistically significant differences were identified during most loading scenarios, the increases in posteromedial displacements and rotatory laxity due to transection of the POL or dMCL were usually small. However, when internal torque was applied to the PCL-deficient knee, the combined torque contributions of the dMCL and POL towards resisting rotation was similar to that of the sMCL.

Conclusion

The dMCL and POL are both important secondary stabilizers to posteromedial translation in the PCL-deficient knee, with alternating roles depending on flexion angle. Thus, in a PCL-deficient knee, concomitant injuries to either the POL or dMCL should be addressed with the aim of reducing the risk of PCL reconstruction failure.

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. Apsingi S, Nguyen T, Bull AMJ, Unwin A, Deehan DJ, Amis AA (2008) 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 36(3):487–494

    Article  Google Scholar 

  2. Ball S, Stephen JM, El-Daou H, Williams A, Amis AA (2020) The medial ligaments and the ACL restrain anteromedial laxity of the knee. KneeSurg Sports TraumatolArthrosc 28:3700–3708

    Article  CAS  Google Scholar 

  3. Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, Engebretsen L, LaPrade RF (2010) An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med 38(2):339–347

    Article  Google Scholar 

  4. Fanelli GC (1993) Posterior cruciate ligament injuries in trauma patients. Arthroscopy 9(3):291–294

    Article  CAS  Google Scholar 

  5. Fanelli GC, Giannotti BF, Edson CJ (1994) The posterior cruciate ligament arthroscopic evaluation and treatment. Arthroscopy 10(6):673–688

    Article  CAS  Google Scholar 

  6. Feng Y, Tsai TY, Li JS, Rubash HE, Li G, Freiberg A (2016) In-vivo analysis of flexion axes of the knee: femoral condylar motion during dynamic knee flexion. ClinBiomech 32:102–107

    Google Scholar 

  7. Griffith CJ, Wijdicks CA, LaPrade RF, Armitage BM, Johansen S, Engebretsen L (2009) Force measurements on the posterior oblique ligament and superficial medial collateral ligament proximal and distal divisions to applied loads. Am J Sports Med 37(1):140–148

    Article  Google Scholar 

  8. Haimes JL, Wroble RR, Grood ES, Noyes FR (1994) Role of the medial structures in the intact and anterior cruciate ligament-deficient Knee: limits of motion in the human knee. Am J Sports Med 22(3):402–409

    Article  CAS  Google Scholar 

  9. Harner CD, Vogrin TM, Höher J, Ma CB, Woo SL (2000) Biomechanical analysis of a posterior cruciate ligament reconstruction: deficiency of the posterolateral structures as a cause of graft failure. Am J Sports Med 28(1):32–39

    Article  CAS  Google Scholar 

  10. Kennedy JC, Hawkins RJ, Willis RB, Danylchuck KD (1976) Tension studies of human knee ligaments. Yield point, ultimate failure, and disruption of the cruciate and tibial collateral ligaments. J Bone Joint Surg 58(3):350–355

    Article  CAS  Google Scholar 

  11. Markolf KL, Graves BR, Sigward SM, Jackson SR, McAllister DR (2007) Effects of posterolateral reconstructions on external tibial rotation and forces in a posterior cruciate ligament graft. J Bone Joint Surg 89(11):2351–2358

    Article  Google Scholar 

  12. Miller MD, Cooper DE, Fanelli GC, Harner CD, LaPrade RF (2002) Posterior cruciate ligament: current concepts. Instr Course Lect 51:347

    PubMed  Google Scholar 

  13. O’Donoghue DH (1959) Surgical treatment of injuries to ligaments of the knee. JAMA 169(3):1423–1431

    Article  Google Scholar 

  14. Ogata K, McCarthy JA, Dunlap J, Manske PR (1988) Pathomechanics of posterior sag of the tibia in posterior cruciate deficient knees: an experimental study. Am J Sports Med 16(6):630–636

    Article  CAS  Google Scholar 

  15. Owens TC (1994) Posteromedial pivot shift of the knee: a new test for rupture of the posterior cruciate ligament. A demonstration in six patients and a study of anatomical specimens. J Bone Joint Surg 76-A:532–539

    Article  Google Scholar 

  16. Pache S, Aman ZS, Kennedy M, Nakama GY, Moatshe G, Ziegler C, LaPrade RF (2018) Posterior cruciate ligament: current concepts review. Arch Bone JtSurg 6(1):8

    Google Scholar 

  17. Petersen W, Loerch S, Schanz S, Raschke M, Zantop T (2008) The role of the posterior oblique ligament in controlling posterior tibial translation in the posterior cruciate ligament-deficient knee. Am J Sports Med 36(3):495–501

    Article  Google Scholar 

  18. Ritchie JR, Bergfeld JA, Kambic H, Manning T (1998) Isolated sectioning of the medial and posteromedial capsular ligaments in the posterior cruciate ligament-deficient knee. Am J Sports Med 26(3):389–394

    Article  CAS  Google Scholar 

  19. Robinson JR, Bull AMJ, Thomas RRD, Amis AA (2006) The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity. Am J Sports Med 34(11):1815–1823

    Article  Google Scholar 

  20. Hammoud S, Reinhardt KR, Marx RG (2010) Outcomes of posterior cruciate ligament treatment: a review of the evidence. Sports Med Arthrosc Rev 18(4):280–291

    Article  Google Scholar 

  21. Sekiya JK, Haemmerle MJ, Stabile KJ, Vogrin TM, Harner CD (2005) Biomechanical analysis of a combined double-bundle posterior cruciate ligament and posterolateral corner reconstruction. Am J Sports Med 33(3):360–369

    Article  Google Scholar 

  22. Shelbourne KD, Davis TJ, Patel DV (1999) The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. Am J Sports Med 27(3):276–283

    Article  CAS  Google Scholar 

  23. Sullivan DE, Levy IM, Sheskier ST, Torzilli PA, Warren RF (1984) Medial restraints to anterior-posterior motion of the knee. J Bone Joint Surg 66-A:930–936

    Article  Google Scholar 

  24. Wierer G, Milinkovic D, Robinson JR, Raschke MJ, Weiler A, Fink C, Herbort M, Kittl C (2020) The superficial medial collateral ligament is the major restraint to anteromedial instability of the knee. KneeSurg Sports TraumatolArthrosc. https://doi.org/10.1007/s00167-020-05947-0

    Article  Google Scholar 

  25. Willing R, Moslemian A, Yamomo G, Wood T, Howard J, Lanting B (2019) Condylar-stabilized tkr may not fully compensate for PCL-deficiency: an in vitro cadaver study. J Orthop Res 37(10):2172–2181

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge the assistance of Mr. Geofrey Yamomo for some of the experimental work related to this study.

Funding

This study was supported by a research grant from Smith and Nephew Inc as well as the Lawson Health Research Institute’s Internal Research Fund. Dr Roessler’s salary was funded by a fellowship grant from Ossur Inc. Dr. Willing receives funding from the Natural Science and Engineering Research Council (NSERC) Discovery Grant RGPIN-2018-05693.

Author information

Authors and Affiliations

  1. Department of Mechanical and Materials Engineering, Western University, London, ON, Canada

    Alireza Moslemian & Ryan Willing

  2. Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada

    Michelle E. Arakgi, Philip P. Roessler, Rajeshwar Singh Sidhu, Ryan M. Degen & Alan M. J. Getgood

Authors
  1. Alireza Moslemian
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michelle E. Arakgi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Philip P. Roessler
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rajeshwar Singh Sidhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ryan M. Degen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ryan Willing
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Alan M. J. Getgood
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AM carried out the specimen preparation, biomechanical testing, statistical analysis and drafted the manuscript. PR and RS assisted with specimen preparation and testing. AM, RW, and AG participated in the design of the study. AM, MA, RD, RW, and AG participated in manuscript preparation and editing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Alan M. J. Getgood.

Ethics declarations

Conflict of interest

AG is a consultant for Smith and Nephew Inc. and Ossur Inc. and receives research support from Smith and Nephew and Ossur.

Ethical approval

As stated in the method section, the use of de-identified specimens does not require research ethics board review at our institution; however, all research, tissue storage, and tissue disposal protocols were reviewed and approved by UTN who are accredited by the American Association of Tissue Banks (#9256).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 261 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Moslemian, A., Arakgi, M.E., Roessler, P.P. et al. The Medial structures of the knee have a significant contribution to posteromedial rotational laxity control in the PCL-deficient knee. Knee Surg Sports Traumatol Arthrosc 29, 4172–4181 (2021). https://doi.org/10.1007/s00167-021-06483-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-021-06483-1

Keywords

Search

Navigation