Muscle activation strategies at the knee during running and cutting maneuvers

PURPOSE: The purpose of this article was to investigate the activation patterns of muscles surrounding the knee during preplanned (PP) and unanticipated (UN) running and cutting tasks, with respect to the external moments applied to the joint. It was hypothesized that activation strategies during PP tasks would correspond to the magnitude and direction of the external loads applied to the knee joint, and the muscle activation patterns would differ between PP and UN tasks. METHODS: Eleven healthy male subjects performed a series of running and cutting tasks under PP and UN conditions. Activation from 10 knee muscles were determined using full-wave rectified, filtered, and normalized EMG calculated during a precontact phase and two epochs across the stance phase. Knee joint flexor and extensor muscle group ratios indicated the level of co-contraction. Individual muscles were also grouped into medial/lateral and internal/external rotation muscle groups, based upon their ability to counter externally applied varus/valgus and internal/external rotation joint loads, respectively. RESULTS: Selective activation of medial/lateral and internal/external rotation muscles and co-contraction of flexors and extensors were used to stabilize the joint under PP conditions, whereas generalized co-contraction strategies were employed during the UN condition. Net muscle activation during the UN sidestepping tasks increased by 10-20%, compared with an approximately 100% increase in applied varus/valgus and internal/external rotation joint moments. CONCLUSION: In PP conditions, activation patterns appear to be selected to support the external loads experienced at the knee, e.g., medial muscles activated to resist applied valgus moments. Under UN conditions, there was no selective activation of muscles to counter the external knee load, with generalized co-contraction being the activation pattern adopted. These findings have implications for the etiology of noncontact knee ligament injuries.     

Anticipatory effects on knee joint loading during running and cutting maneuvers.

PURPOSE: To determine how unanticipated performance of cutting maneuvers in sport affects the external loads applied to the knee joint and the potential risk for ligament injury. METHODS: A 50-Hz VICON motion analysis system was used to determine the lower limb kinematics of 11 healthy male subjects during running and cutting tasks performed under preplanned (PP) and unanticipated (UN) conditions. Subjects performed the UN tasks in response to a light stimulus on a target board. A kinematic model was then used in conjunction with force place data to calculate the three-dimensional loads at the knee joint. RESULTS: External flexion/extension moments at the knee joint were similar between PP and UN conditions; however, the varus/valgus and internal/external rotation moments during the UN cutting tasks were up to twice the magnitude of the moments measured during the PP condition. CONCLUSION: Cutting maneuvers performed without adequate planning may increase the risk of noncontact knee ligament injury due to the increased external varus/valgus and internal/external rotation moments applied to the knee. These results are probably due to the small amount of time to make appropriate postural adjustments before performance of the task, such as the position of the foot on the ground relative to the body center of mass. Subsequently, training for the game situation should involve drills that familiarize players with making unanticipated changes of direction. Practice sessions should also incorporate plyometrics and should focus on better interpretation of visual cues to increase the time available to preplan a movement.     

Prolonged running increases knee moments in sidestepping and cutting manoeuvres in sport

Objectives

To investigate how knee kinematics, kinetics and loading changes during sidestepping tasks following a prolonged running protocol performed in a laboratory setting.

Neuromuscular biomechanical modeling to understand knee ligament loading

PURPOSE: This article examines our use of EMG-driven neuromuscular biomechanical models to study how muscles stabilize the knee. EMG can be used to establish which activation patterns are used by people for knee stabilization. However, it does not reveal the effectiveness of these patterns. The EMG-driven models provide quantitative comparisons of the effectiveness of the different knee-stabilizing activation patterns. METHODS: Subjects performed static tasks and common sporting maneuvers that challenged knee joint stability. EMG, joint posture and motion, and external forces and moments were measured during these tasks. These data were used to calibrate the EMG-driven neuromuscular biomechanical model. We then used the model to predict the role of muscles in supporting varus and valgus moments at the knee. RESULTS: We found specific muscle activation patterns to support varus and valgus moments. The most potent activation pattern to stabilize the knee is when the hamstrings or quadriceps are required to generate flexion or extension moments, respectively. The next most effective knee-stabilizing pattern is cocontraction of the hamstring and quadriceps. The small biarticular muscles at the knee provided the least support of varus and valgus moments. In the sporting tasks, sidestepping was found to place the anterior cruciate ligament at high risk of injury. We found that the muscles are the main defense against knee ligament injuries in these tasks. CONCLUSION: Traditional biomechanical and neurophysiological methods have shown that there are specific activation patterns used to stabilize the knee. By also using the EMG-driven neuromuscular biomechanical model, we have shown how effective muscles are in stabilizing the knee. This modeling method provides a new tool to understand knee joint stabilization.     

Rearfoot strikes more frequently apply combined knee valgus and tibial internal rotation moments than forefoot strikes in females during the early phase of cutting maneuvers

BackgroundAnterior cruciate ligament (ACL) injury often occurs during deceleration maneuvers in sports. Combined knee valgus and tibial internal rotation (VL + IR) moments have been recognized as a risk leading to ACL injury; however, it is unknown how the foot strike pattern (forefoot or rearfoot strike) affects the occurrence rate of the aforementioned combined knee moments during cutting maneuvers.Research questionTo test the hypothesis that rearfoot strikes rather than forefoot strikes show a significantly higher occurrence rate of the combined VL + IR moments during the early stance phase of a cutting maneuver.MethodsTwenty-four females performed 60° cutting maneuvers under rearfoot and forefoot strike conditions. Positional data of lower limb markers and ground reaction force (GRF) were collected. Knee varus/valgus and tibial internal/external rotation moments due to GRF were calculated and time-normalized (0–100 %) to the stance phase. The occurrence rates of combined VL + IR moments were compared between rearfoot and forefoot strike conditions throughout the stance (chi-squared test, p < 0.01). Furthermore, the time patterns of the two knee moments and the position of the GRF acting point were compared using the statistical parametric mapping paired t-test (p < 0.0125).ResultsRearfoot strikes more frequently produced combined VL + IR moments than forefoot strikes (maximum occurrence rates: 73.5 % vs. 27.8 %, p < 0.01) during the first 0–40 % of the stance. Both foot strikes consistently showed an increase in knee valgus moment soon after foot impact; however, rearfoot and forefoot strikes respectively applied opposite internal and external rotation moments during the first 0–7 % of stance (p < 0.0125), indicating that the GRF vector that generated knee valgus moment further applied tibial internal rotation moment when it acted posterior to the tibial rotation axis.SignificanceThe current results suggest that rearfoot strike in cuttings elevates the probability of ACL injury via combined VL + IR moments.     

The effect of technique change on knee loads during sidestep cutting

PURPOSE: To identify the effect of modifying sidestep cutting technique on knee loads and predict what impact such change would have on the risk of noncontact anterior cruciate ligament injury. METHODS: A force platform and motion-analysis system were used to record ground-reaction forces and track the trajectories of markers on 15 healthy males performing sidestep cutting tasks using their normal technique and nine different imposed techniques. A kinematic and inverse dynamic model was used to calculate the three-dimensional knee postures and moments. RESULTS: The imposed techniques of foot wide and torso leaning in the opposite direction to the cut resulted in increased peak valgus moments experienced in weight acceptance. Higher peak internal rotation moments were found for the foot wide and torso rotation in the opposite direction to the cut techniques. The foot rotated in technique resulted in lower mean flexion/extension moments, whereas the foot wide condition resulted in higher mean flexion/extension moments. The flexed knee, torso rotated in the opposite direction to the cut and torso leaning in the same direction as the cut techniques had significantly more knee flexion at heel strike. CONCLUSION: Sidestep cutting technique had a significant effect on loads experienced at the knee. The techniques that produced higher valgus and internal rotation moments at the knee, such as foot wide, torso leaning in the opposite direction to the cut and torso rotating in the opposite direction to the cut, may place an athlete at higher risk of injury because these knee loads have been shown to increase the strain on the anterior cruciate ligament. Training athletes to avoid such body positions may result in a reduced risk of noncontact anterior cruciate ligament injures.     

Lower extremity kinematics and kinetics of Division III collegiate baseball and softball players while performing a modified pro-agility task

AIM: Females experience at least twice as many non-contact anterior cruciate ligament (ACL) injuries as males. The aim of this study was to investigate if males and females exhibited different characteristics while performing a modified pro-agility test. METHODS: Collegiate Division III male baseball (n=14) and female softball (n=13) players performed 4 trials of a modified pro-agility task, which consisted of running toward a force platform target for 5 steps, planting their right foot, and propelling themselves off of the target with their left foot. Kinematic and kinetic parameters were compared using a multivariate analysis of variance between gender with the level of significance set at P<0.05. RESULTS: Males and females exhibited similar knee valgus angles. Females had a greater maximum knee extension angle (10.14 degrees vs 17.43 degrees ), and greater knee range of motion (46.12 degrees vs 40.12 degrees ). Both groups reached maximum knee flexion at 52% of stance. Females had significantly more maximum hip flexion than males (28.86 degrees vs 22.75 degrees ). Females had significantly smaller minimum internal knee varus moments than their male counterparts (1.12 Nm/kg vs 1.55 Nm/kg). Vertical ground reaction forces as a percentage of bodyweight, and stance time, were not statistically different. The female group displayed an external knee rotation angle (2.49 degrees ) during the beginning of their stance, which was significantly different than the internal rotation angle (4.11 degrees ) in the male group. Early in stance knee rotation angle was highly correlated with the lack of internal knee varus moment (males R(2)=0.75, females R(2)=0.88). CONCLUSION: Females displayed knee moments and kinematics that may place them at greater risk for ACL injury during a stop-cut task. Females should be coached to perform stop cuts with more knee flexion and a more neutral knee rotation angle upon foot contact in an effort to reduce moments that may place the ACL at risk.     

Knee joint kinematics during the sidestep cutting maneuver: potential for injury in women.

PURPOSE: There is a paucity of data describing female lower limb biomechanics during "high risk" movements linked to noncontact ACL injury. This study compared, across gender, knee kinematics associated with sidestepping maneuvers to provide insight into why women display a significantly higher incidence of this injury than do men. METHODS: Thirty participants (16 men, 14 women) had bilateral knee joint kinematic data recorded while sidestepping. A custom software package (JTMOTION) quantified maximum, minimum, and range of motion during stance for each of the three clinical knee joint rotations (flexion/extension, adduction/abduction and external/internal rotation) over 20 (leg x condition x trial (5)) trials. RESULTS: Gender differences possessed limited clinical significance with all maximum values well within safe ranges of knee motion. Women did, however, display increased intertrial variability for axial rotation patterns during cutting compared with men. This variability was thought to be unaffected by gender, with experience level found statistically (P < 0.01) to be the major determinant of knee kinematic variability during sidestepping. Hence, the level of exposure to sidestep cutting may have a large impact on the subsequent risk of ACL injury when when one performs these maneuvers. CONCLUSIONS: Gender differences in knee motions during cutting did not contribute to the increased risk of noncontact ACL injury in women compared with men. The reasons for this increased incidence, therefore, remain unclear. The potential relationship between gender and other parameters linked to ACL injury such as joint geometry, ligament morphology, and physical conditioning requires further investigation.     

Effect of gender and defensive opponent on the biomechanics of sidestep cutting

PURPOSE: Anterior cruciate ligament (ACL) injuries often occur in women during cutting maneuvers to evade a defensive player. Gender differences in knee kinematics have been observed, but it is not known to what extent these are linked to abnormal neuromuscular control elsewhere in the kinetic chain. Responses to defense players, which may be gender-dependent, have not been included in previous studies. This study determined the effects of gender and defense player on entire lower extremity biomechanics during sidestepping. METHODS: Eight male and eight female subjects performed sidestep cuts with and without a static defensive opponent while 3D motion and ground reaction force data were recorded. Peak values of eight selected motion and force variables were, as well as their between-trial variabilities, submitted to a two-way (defense x gender) ANOVA. A Bonferroni-corrected alpha level of 0.003 denoted statistical significance. RESULTS: Females had less hip and knee flexion, hip and knee internal rotation, and hip abduction. Females had higher knee valgus and foot pronation angles, and increased variability in knee valgus and internal rotation. Increased medial ground reaction forces and flexion and abduction in the hip and knee occurred with the defensive player for both genders. CONCLUSIONS: A simulated defense player causes increased lower limb movements and forces, and should be a useful addition to laboratory protocols for sidestepping. Gender differences in the joint kinematics suggest that increased knee valgus may contribute to ACL injury risk in women, and that the hip and ankle may play an important role in controlling knee valgus during sidestepping. Consideration of the entire lower extremity contributes to an understanding of injury mechanisms and may lead to better training programs for injury prevention.     

Force measurements on the fibular collateral ligament, popliteofibular ligament, and popliteus tendon to applied loads

BACKGROUND: Little information is known about the forces seen on the main individual structures of the posterolateral knee to applied loads. This information is needed to determine which structures should be reconstructed and also the relative strengths needed for reconstruction grafts. PURPOSE: To determine in vitro forces in the fibular collateral ligament, popliteofibular ligament, and popliteus tendon for various posterolateral knee loading conditions. STUDY DESIGN: Cadaveric study. RESULTS: The fibular collateral ligament was loaded in varus, internal rotation, and external rotation. The highest amount of force seen on the fibular collateral ligament was at 0 degrees of knee flexion with external rotation, with the mean load response to external rotation significantly less at 90 degrees . Fibular collateral ligament varus load response at 0 degrees , 30 degrees , and 60 degrees was fairly constant, with a significant decrease at 90 degrees compared to 30 degrees of knee flexion. The popliteus tendon and popliteofibular ligament were loaded with an external rotation moment and were noted to have similar loading patterns. The mean load response on both the popliteus tendon and the popliteofibular ligament peaked at 60 degrees of knee flexion. The mean popliteus tendon and popliteofibular ligament load response at 0 degrees was significantly less than the mean load response at 30 degrees , 60 degrees , and 90 degrees of knee flexion. CONCLUSIONS: High relative loads were seen on the fibular collateral ligament with varus and external rotation and on the popliteus tendon and popliteofibular ligament, with external rotation. A reciprocal relationship of load sharing in external rotation depending on knee flexion angle was revealed that has not been previously reported. The force on the fibular collateral ligament with external rotation loads was higher than the load on the popliteus complex at lower flexion angles, with the popliteus complex having higher load sharing at 60 degrees and 90 degrees of knee flexion. These results provide a measure of the potential for failure of these structures with joint loading and guidelines for both graft strength requirements for surgical reconstructions and postoperative rehabilitation protocols.     

Physiological coxa varus–genu valgus influences internal knee and ankle joint moments in females during crossover cutting

This study evaluated the ankle and knee electromyographic, kinematic, and kinetic differences of 20 nonimpaired females with either neutral (group 1) or coxa varus–genu valgus (group 2) alignment during crossover cutting stance phase. Two-way mixed model ANOVA (group, session) assessed mean differences (p<0.05) and correlation analysis further delineated relationships. During impact absorption, group 2 displayed earlier peak horizontal braking (anterior-posterior) ground reaction force timing, decreased and earlier peak internal knee extension moments (eccentric function), and earlier peak internal ankle dorsiflexion moment timing (eccentric function). During the pivot phase, group 2 displayed later and eccentrically-biased peak ankle plantar flexion moments, increased peak internal knee flexion moments (eccentric function), and later peak knee internal rotation timing. Correlation analysis revealed that during impact absorption, subjects with coxa varus–genu valgus alignment (group 2) displayed a stronger relationship between knee internal rotation velocity and peak internal ankle dorsiflexion moment onset timing (r=–0.64 vs r =–0.26) and between peak horizontal braking ground reaction forces and peak internal ankle dorsiflexion moment onset timing (r=0.61 vs r=0.24). During the pivot phase these subjects displayed a stronger relationship between peak horizontal braking ground reaction forces and peak internal ankle plantar flexion moment onset timing (r=–0.63 vs r=–0.09) and between peak horizontal braking forces and peak internal ankle plantar flexion moments (r=–0.72 vs r=–0.26). Group differences suggest that subjects with coxa varus–genu valgus frontal-plane alignment have an increased dependence on both ankle dorsiflexor and plantar flexor muscle group function during crossover cutting. Greater dependence on ankle muscle group function during the performance of a task that requires considerable 3D dynamic knee joint control suggests a greater need for frontal and transverse plane weight bearing tasks that facilitate eccentric ankle muscle group function to optimize injury prevention conditioning and post-surgical rehabilitation programs.     

The effects of grade III posterolateral knee complex injuries on anterior cruciate ligament graft force. A biomechanical analysis.

To determine if untreated grade III injuries of the posterolateral structures contribute to increased force on an anterior cruciate ligament graft, we measured the force in the graft in cadaveric knees during joint loading after reconstruction with otherwise intact structures and in the same reconstructed knees after selected cutting of specific posterolateral knee structures. Tests were first performed on the knee with the posterolateral structures intact and then after sequential sectioning of the fibular collateral ligament, popliteofibular ligament, and popliteus tendon. The graft force was significantly higher after fibular collateral ligament transection during varus loading at both 0 degree and 30 degrees of knee flexion than it was for the same loading of the joint with intact posterolateral structures. In addition, coupled loading of varus and internal rotation moments at 0 degree and 30 degrees of flexion further increased graft force beyond that with varus force alone. The increase in graft force remained significant with additional sequential cutting of the popliteofibular ligament and popliteus tendon. We believe this study supports the clinical observation that untreated grade III posterolateral structure injuries contribute to anterior cruciate ligament graft failure by allowing higher forces to stress the graft.     

The effect of injury to the posterolateral structures of the knee on force in a posterior cruciate ligament graft: a biomechanical study

To determine whether untreated grade 3 posterolateral knee injuries contribute to a significant increase in force on a posterior cruciate ligament reconstruction graft, we measured the force on the graft during joint loading of a posterior cruciate ligament-reconstructed knee with otherwise intact structures and then selectively cut the popliteofibular ligament, popliteus tendon, and the fibular collateral ligament. A posterior cruciate ligament reconstruction was performed in eight fresh-frozen cadaveric knees. One end of the graft was fixed to a tensioning jig with a load cell used to measure force in the graft as loads were applied to the knee. The force on the graft was significantly higher with the posterolateral structures cut during varus loading at 30 degrees, 60 degrees, and 90 degrees of flexion than it was in the same joint under the same loading conditions but with the posterolateral structures intact. Additionally, coupled loading of posterior drawer force and external tibial torque at 30 degrees, 60 degrees, and 90 degrees significantly increased force on the graft with the posterolateral structures cut. There was no significant increase in force on the graft under any condition with a posterior force, valgus force, or internal and external tibial torque applied alone. A significant increase in force occurs in a posterior cruciate ligament graft in knees with deficient posterolateral knee structures. We recommend that in knees with grade 3 posterolateral injuries and evidence of varus or coupled posterior-external rotation instability the posterolateral structures be repaired or reconstructed at the time of posterior cruciate ligament reconstruction to decrease the chance of later graft failure.     

Coordination and variability during anticipated and unanticipated sidestepping

BackgroundNumerous investigations have attempted to link the incidence and risk of non-contact anterior cruciate ligament injuries to specific intrinsic and extrinsic mechanisms. However, these are often measured in isolation.Research questionThis study utilizes a dynamical systems approach to investigate differences in coordination and coordination variability between segments and joints in anticipated and unanticipated sidestepping, a task linked to a high risk of non-contact anterior cruciate ligament injuries.MethodsFull body, three-dimensional kinematics and knee kinetic data were collected on 22 male collegiate soccer players during anticipated and unanticipated sidestepping tasks. A modified vector coding technique was used to quantify coordination and coordination variability of the trunk and pelvis segments and the hip and knee joints.ResultsSagittal and frontal plane trunk-pelvis coordination were more in-phase during unanticipated sidestepping. Sagittal plane hip-knee and hip (rotation)-knee (flexion/extension) coordination were more in-phase with the knee dominating the movement during unanticipated sidestepping (P < 0.05). Coordination variability was greater in unanticipated sidestepping for trunk (flexion)-pelvis (tilt), trunk (lateral flexion)-pelvis (obliquity), hip (flexion/extension)-knee (flexion/extension) and hip (rotation)-knee (flexion/extension) (P < 0.05). In unanticipated sidestepping where there is limited time to pre-plan the movement, multiple kinematic solutions and high coordinative variability is required to achieve the task.SignificanceOur results suggest that coordination becomes more in-phase and the variability of this coordination increases as a function of task complexity and reduced planning time as that which occurs in unanticipated sporting task scenarios. Consequently, injury prevention programs must incorporate perceptual components in order to optimise planning time and coordinate appropriate postural adjustments to reduce external knee joint loading and subsequent injury risk in sport.     

The role of the medial collateral ligament and posteromedial capsule in controlling knee laxity

BACKGROUND: The medial aspect of the knee has a complex capsular structure; the biomechanical roles of specific structures are not well understood. HYPOTHESIS: The 3 strong stabilizing structures, the superficial and deep medial collateral ligaments and the posteromedial capsule, make distinct contributions to controlling tibiofemoral laxity. STUDY DESIGN: Controlled laboratory study. METHODS: Changes in knee laxity under anterior-posterior drawer, valgus, and internal-external rotation loads were found by sequential cutting in 18 cadaveric knees. Three cutting sequences allowed the roles of the 3 structures to be seen in isolation and in combination. Some force contributions were also calculated. RESULTS: The posteromedial capsule controlled valgus, internal rotation, and posterior drawer in extension, resisting 42% of a 150-N drawer force when the tibia was in internal rotation. The superficial collateral ligament controlled valgus at all angles and was dominant from 30 degrees to 90 degrees of flexion, plus internal rotation in flexion. The deep collateral ligament controlled tibial anterior drawer of the flexed and externally rotated knee and was a secondary restraint to valgus. CONCLUSION: Distinct roles in controlling tibiofemoral laxity have been found for these structures that vary according to knee flexion and tibial rotation. CLINICAL RELEVANCE: The restraining functions demonstrated provide new information about knee stabilization, which may allow better evaluation of structural damage at the medial aspect of the knee.     

Treatment of the medial collateral ligament injury. I: The importance of anterior cruciate ligament on the varus-valgus knee laxity

The purpose of this study was to explain the functional roles of the medial collateral ligament (MCL) and the ACL and how they affect the kinematics of the knee joint after isolated MCL injury. Varus-valgus joint laxity was quantitatively measured using a device which allowed various degrees of freedom (DOF) of joint motion during application of a varus-valgus bending moment to the canine knee joint. When the knee motion was limited to 3 DOF (varus-valgus rotation, proximal-distal, and medial-lateral translation), valgus laxity increased significantly (171%) after sectioning the MCL. Thus, the MCL was the primary restraint to the valgus bending moment in the 3 DOF mode. However, the effect of sectioning the MCL on valgus laxity became minimal (21% increase) when the DOF of knee motion was increased to 5 (by adding axial tibial rotation and anterior-posterior translation). In this situation, external and internal tibial axial rotation were coupled with the varus and valgus rotation of the knee joint, respectively, and the ACL also functioned to restrain the varus-valgus rotation. The results of this study suggest that under normal knee joint motion, the functional deficit of the MCL in valgus rotation was compensated for by the remaining structures, especially by the ACL.     

How well do anatomical reconstructions of the posterolateral corner restore varus stability to the posterior cruciate ligament-reconstructed knee?

BACKGROUND: With grade 3 posterolateral injuries of the knee, reconstructions of the lateral collateral ligament, popliteus tendon, and popliteofibular ligament are commonly performed in conjunction with a posterior cruciate ligament reconstruction to restore knee stability. HYPOTHESIS: A lateral collateral ligament reconstruction, alone or with a popliteus tendon or popliteofibular ligament reconstruction, will produce normal varus rotation patterns and restore posterior cruciate ligament graft forces to normal levels in response to an applied varus moment. STUDY DESIGN: Controlled laboratory study. METHODS: Forces in the native posterior cruciate ligament were recorded for 15 intact knees during passive extension from 120 degrees to 0 degrees with an applied 5 N .m varus moment. The posterior cruciate ligament was removed and reconstructed with a single bundle inlay graft tensioned to restore intact knee laxity at 90 degrees . Posterior cruciate ligament graft force, varus rotation, and tibial rotation were recorded before and after a grade 3 posterolateral corner injury. Testing was repeated with lateral collateral ligament, lateral collateral ligament plus popliteus tendon, and lateral collateral ligament plus popliteofibular ligament graft reconstructions; all grafts were tensioned to 30 N at 30 degrees with the tibia locked in neutral rotation. RESULTS: All 3 posterolateral graft combinations rotated the tibia into slight valgus as the knee was taken through a passive range of motion. During the varus test, popliteus tendon and popliteofibular ligament reconstructions internally rotated the tibia from 1.5 degrees (0 degrees flexion) to approximately 12 degrees (45 degrees flexion). With an applied varus moment, mean varus rotations with a lateral collateral ligament graft were significantly less than those with the intact lateral collateral ligament beyond 0 degrees flexion; mean decreases ranged from 0.8 degrees (at 5 degrees flexion) to 5.6 degrees (at 120 degrees flexion). Addition of a popliteus tendon or popliteofibular ligament graft further reduced varus rotation (compared with a lateral collateral ligament graft) beyond 25 degrees of flexion; both grafts had equal effects. A lateral collateral ligament reconstruction alone restored posterior cruciate ligament graft forces to normal levels between 0 degrees and 100 degrees of flexion; lateral collateral ligament plus popliteus tendon and lateral collateral ligament plus popliteofibular ligament reconstructions reduced posterior cruciate ligament graft forces to below-normal levels-beyond 95 degrees and 85 degrees of flexion, respectively. CONCLUSIONS: With a grade 3 posterolateral corner injury, popliteus tendon or popliteofibular ligament reconstructions are commonly performed to limit external tibial rotation; we found that they also limited varus rotation. With the graft tensioning protocols used in this study, all posterolateral graft combinations tested overconstrained varus rotation. Further studies with posterolateral reconstructions are required to better restore normal kinematics and provide more optimum load sharing between the PCL graft and posterolateral grafts. CLINICAL RELEVANCE: A lower level of posterolateral graft tension, perhaps applied at a different flexion angle, may be indicated to better restore normal varus stability. The clinical implications of overconstraining varus rotation are unknown.     

The effect of anterior cruciate ligament reconstruction on knee joint kinematics under simulated muscle loads

BACKGROUND: Numerous studies have investigated anterior stability of the knee during the anterior drawer test after anterior cruciate ligament reconstruction. Few studies have evaluated anterior cruciate ligament reconstruction under physiological loads. PURPOSE: To determine whether anterior cruciate ligament reconstruction reproduced knee motion under simulated muscle loads. STUDY DESIGN: Controlled laboratory study. METHODS: Eight human cadaveric knees were tested with the anterior cruciate ligament intact, transected, and reconstructed (using a bone-patellar tendon-bone graft) on a robotic testing system. Tibial translation and rotation were measured at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion under anterior drawer loading (130 N), quadriceps muscle loading (400 N), and combined quadriceps and hamstring muscle loading (400 N and 200 N, respectively). Repeated-measures analysis of variance and the Student-Newman-Keuls test were used to detect statistically significant differences between knee states. RESULTS: Anterior cruciate ligament reconstruction resulted in a clinically satisfactory anterior tibial translation. The anterior tibial translation of the reconstructed knee was 1.93 mm larger than the intact knee at 30 degrees of flexion under anterior load. Anterior cruciate ligament reconstruction overconstrained tibial rotation, causing significantly less internal tibial rotation in the reconstructed knee at low flexion angles (0 degrees-30 degrees) under muscle loads (P < .05). At 30 degrees of flexion, under muscle loads, the tibia of the reconstructed knee was 1.9 degrees externally rotated compared to the intact knee. CONCLUSIONS: Anterior cruciate ligament reconstruction may not restore the rotational kinematics of the intact knee under muscle loads, even though anterior tibial translation was restored to a clinically satisfactory level under anterior drawer loads. These data suggest that reproducing anterior stability under anterior tibial loads may not ensure that knee joint kinematics is restored under physiological loading conditions. CLINICAL RELEVANCE: Decreased internal rotation of the knee after anterior cruciate ligament reconstruction may lead to increased patellofemoral joint contact pressures. Future anterior cruciate ligament reconstruction techniques should aim at restoring 3-dimensional knee kinematics under physiological loads.     

An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique

BACKGROUND: To date, no surgical technique to treat posterolateral knee instability anatomically reconstructs the 3 major static stabilizing structures of the posterolateral knee: the fibular collateral ligament, the popliteus tendon, and the popliteofibular ligament. HYPOTHESIS: Static varus and external rotatory stability would be restored to the reconstructed knee with a posterolateral knee injury. METHODS: The anatomical locations of the original fibular collateral ligament, popliteus tendon, and popliteofibular ligament were reconstructed using a 2-graft technique. Ten cadaveric specimens were tested in 3 states: intact knee, knee with the 3 structures cut to simulate a grade III injury, and the reconstructed knee. RESULTS: For the varus loading tests, joint stability was significantly improved by the posterolateral reconstruction compared to the cut state at 0 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion. There were no significant differences between the intact and reconstructed knees at 0 degrees, 60 degrees, and 90 degrees for varus translation. For the external rotation torque tests, external rotation was significantly higher for the cut state than for the intact or reconstructed posterolateral knee. There was no significant difference in external rotation between the intact and reconstructed posterolateral knees at any flexion angle. CONCLUSIONS: This 2-graft technique to reconstruct the primary static stabilizers of the posterolateral knee restored static stability, as measured by joint translation in response to varus loading and external rotation torque, to knees with grade III posterolateral injuries.