And Forces in A Posterior Cruciate Ligament Graft Effects of Posterolateral Reconstructions On External Tibial Rotation
And Forces in A Posterior Cruciate Ligament Graft Effects of Posterolateral Reconstructions On External Tibial Rotation
And Forces in A Posterior Cruciate Ligament Graft Effects of Posterolateral Reconstructions On External Tibial Rotation
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2351
COPYRIGHT 2007
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Background: In patients with a Grade-3 injury, reconstructions of the lateral collateral ligament, popliteus tendon,
and popliteofibular ligament are commonly performed in conjunction with a reconstruction of the posterior cruciate
ligament. The objectives of this study were (1) to compare the abilities of three types of posterolateral graft reconstruction to restrain external tibial rotation and alter forces in a posterior cruciate graft and (2) to compare tibial rotations and posterior cruciate graft forces associated with two levels of initial posterolateral graft tension.
Methods: Forces in the posterior cruciate ligament were recorded as the knee was extended from 120 to 0 and a 5N-m external tibial torque was applied. The posterior cruciate ligament was reconstructed, and external tibial rotation
and the forces in the posterior cruciate graft were recorded. These measurements were again recorded after sectioning
of the posterolateral structures and after reconstruction of the lateral collateral ligament, alone as well as in combination with reconstruction of the popliteus tendon and in combination with reconstruction of the popliteofibular ligament.
Results: With the lateral collateral ligament intact, removal of the popliteus tendon from its femoral origin significantly increased external tibial rotation. Applying tension to a popliteus or popliteofibular graft internally rotated the
tibia, with no significant difference between the rotations caused by the tensioning of the two grafts. Tibial rotation
was significantly greater when graft tensioning had been performed with the tibia free to rotate than it was when the
tensioning had been done with the tibia locked in neutral rotation. With an applied external tibial torque, a reconstruction of the lateral collateral ligament alone was not sufficient to reduce posterior cruciate graft forces to normal. The
addition of a popliteus or popliteofibular reconstruction to the lateral collateral ligament reconstruction significantly
reduced posterior cruciate graft forces to normal (or below normal) levels. The external rotations associated with
these two combined reconstructions were equivalent and significantly less than that in the intact knee. Increasing
tension in either the popliteus or the popliteofibular graft from 10 to 30 N significantly decreased external rotation.
Conclusions: The posterolateral grafts acted to resist applied external torque, thereby off-loading the posterior cruciate graft. Popliteus and popliteofibular grafts were more favorably aligned than a lateral collateral ligament graft to resist external rotation, and they had similar effects.
Clinical Relevance: Holding the tibia in neutral rotation when tensioning a popliteus or popliteofibular graft will help
limit internal tibial rotation. The popliteus and popliteofibular graft tensioning protocols used in this study overly constrained external rotation and failed to produce optimal load-sharing with the posterior cruciate graft.
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or
grants in excess of $10,000 from NFL Charities. Neither they nor a member of their immediate families received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any
benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a
member of their immediate families, are affiliated or associated.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our
subscription department, at 781-449-9780, to order the CD-ROM).
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Fig. 1
The combined reconstruction of the lateral collateral ligament (LCL) and the popliteus tendon (POP). The bone block of the
lateral collateral ligament graft is fixed on the lateral femoral condyle at the center of the native footprint of the lateral collateral ligament. The distal end of the graft passes through a tunnel on the fibular head. Lines sutured to the end of the graft
pass through a split clamp (fixed to the tibia) for graft tensioning and fixation. The bone block of the popliteus graft is fixed
near the center of the popliteus footprint on the lateral femoral condyle and passes through a tunnel drilled into the fibular
styloid. When used for a popliteus reconstruction, the same graft passes through a tunnel drilled 1 cm inferior to the lateral
tibial plateau. PFL = popliteofibular ligament. (Reprinted, with permission, from: Markolf KL, Graves BR, Sigward SM, Jackson SR, McAllister DR. How well do anatomical reconstructions of the posterolateral corner restore varus stability to the
posterior cruciate ligament-reconstructed knee? Am J Sports Med. 2007;35:1117-22.)
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Fig. 2
E F F E C T S O F P O S T E RO L A T E R A L R E CO N S T R U C T I O N S O N T I B I A L
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significantly different from those with all posterolateral structures intact beyond 25 of flexion, and they were approximately 3.5 greater between 0 and 25 of flexion (Fig. 4). The
mean rotations with 10 N of tension on the lateral collateral
ligament graft were not significantly different from those with
30 N of tension. The mean rotations with the popliteus and
popliteofibular grafts were significantly less than those with all
posterolateral structures intact, with one exception (the popliteus graft at 0) (Fig. 4). The mean rotations with both grafts
were approximately 2 greater with 10 N of graft tension than
they were with 30 N. The mean rotations with the popliteus
and popliteofibular grafts were not significantly different from
each other at either tension level.
With the tibia free to rotate, applying 30 N of tension to a
popliteus or popliteofibular graft rotated the tibia internally to
5.5 at 0 of flexion and to 15.6 at 120 of flexion. There was
significantly less mean internal rotation when the tibia was
locked during tensioning (1.8 to 9.8, respectively) (Fig. 5).
For these tests, the lateral collateral ligament was intact and the
knee was passively flexed through a 120 range of motion with
no external tibial torque applied. The mean rotation with the
popliteus graft did not differ significantly from that with the
popliteofibular graft at either pretension condition (Fig. 5).
The mean forces in the posterior cruciate graft with a
lateral collateral ligament reconstruction alone were significantly greater than those in the posterior cruciate ligament beyond 80 of flexion (Fig. 6). The mean posterior cruciate graft
Fig. 3
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Fig. 4
E F F E C T S O F P O S T E RO L A T E R A L R E CO N S T R U C T I O N S O N T I B I A L
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Fig. 5
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Fig. 6
Mean curves of resultant force versus knee flexion angle produced by application of 5 N-m of external tibial torque in the fifteen knees, with the posterior cruciate ligament (pcl) intact and with a posterior cruciate ligament graft and (1) all posterolateral structures intact, (2) a lateral collateral ligament (lcl) graft tensioned to 10 or 30 N, (3) a lateral collateral ligament
graft tensioned to 30 N and a popliteus (pop) graft tensioned to 10 or 30 N, and (4) a lateral collateral ligament graft tensioned to 30 N and popliteofibular (pfl) graft tensioned to 10 or 30 N. Sample standard deviations are indicated by error
bars. ns = no significant difference between test conditions at the indicated degrees of flexion.
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