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The Knee Joint

New York
Hong Kong
The Knee Joint
Surgical Techniques and Strategies

Michel Bonnin
Annunziato Amendola
Johan Bellemans
Steven MacDonald
Jacques Ménétrey
Michel Bonnin Steven MacDonald
Centre Orthopédique Santy London Health Sciences Centre
24, avenue Paul Santy University Campus
69008 Lyon University of Western Ontario
France 339 Windermere Road
London, ON, N6A 5A5
Annunziato Amendola
University of Iowa
Hospitals and Clinics Jacques Ménétrey
200 Hawkins Drive Clinique et polyclinique
01018 JPP Iowa Cit d’orthopédie de l’appareil moteur
IA, 52242-1088 Hôpital universitaire de Genève
USA 24, rue Micheli-du-Crest
Johan Bellemans 1211 Genève 14
Weligerveld 1 Suisse
3212 Pellenberg

ISBN : 978-2-287-99352-7 Springer Paris Berlin Heidelberg New York

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Illustration of cover: Marc Donon

Cover design: Jean-François Montmarché
Layout: Nord-Compo - Villeneuve d’Ascq
List of Contributors

M. Aboelnour 745-9 Dunstable Road

Department of Orthopaedics, MA Mansoura Luton
University, Mansoura, Egypt, Germany Beds LU4 0HL

J. D. Agneskirchner Jean-Manuel Aubaniac

DK Henriettenstiftung Hannover, Department of Orthopedic Surgery,
D-30171 Hannover, Marienstrasse 72-90, Aix-Marseille University,
Germany Hopital Sainte-Marguerite,
Marseille, France
T. Ait Si Selmi
Centre Orthopédique Santy Xavier Ayral
24, avenue Paul Santy Service de Rhumatologie B
69008 Lyon France Hôpital Cochin
27, rue du faubourg Saint Jacques
Sam Akhavan 75014 Paris, France
Orthopaedic Sports Research and Clinical,
Cleveland Clinic Sports Health, Cleveland Roger Badet
Clinic Foundation, Cleveland, Ohio USA Pôle ostéo-articulaire santé et sport
60, avenue du Médipôle
Karl Fredrik Almqvist 38300 Bourgoin Jallieu, France
Department of Traumatology and Orthopaedic
Surgery, Ghent University, Roald Bahr
Belgium Oslo Sports Trauma Research Center,
Norwegian School of Sport Sciences,
Annunziato Amendola PB 4014 Ullevål Stadion, 0806 Oslo, Norway
University of Iowa Sports Medicine Center,
University of Iowa Hospitals and Clinics, C. Lowry Barnes
200 Hawkins Dr., Iowa city, Iowa, 52242 USA Arkansas Specialty Orthopaedics,
600 South McKinley, Suite 405,
Andrew A. Amis Little Rock, Arkansas, 72205, USA
Biomechanics Section, Mechanical Engineering
Department, Imperial College London, Philippe Beaufils
London SW7 2AZ, UK Orthopaedic Department
Versailles Hospital
Elizabeth A. Arendt F-78150 Le Chesnay, France
Department of Orthopaedic Surgery,
University of Minnesota, Minneapolis, MN 55454 Johan Bellemans
Department of Orthopaedic Surgery,
Jean-Noel A. Argenson University Hospitals Leuven, Belgium
Department of Orthopedic Surgery Universitaire Ziekenhuizen KU Leuven,
Aix-Marseille University campus Pellenberg, Weligerveld 1,
Hospital Sainte-Marguerite, Marseille, France 3212 Pellenberg, Belgium
Department of Orthopaedics,
Abdullah Ashour University hospitals Leuven,
Department of Orthopedic Surgery, Herestraat 49 B-3000 Leuven, Belgium
Aix-Marseille University,
Hospital Sainte-Marguerite, Marseille, France Guy Bellier
Orthopaedic Surgery
Sunil Apsingi 23, avenue Niel
24 The Drummonds 75017 Paris, France
VI The Knee Joint

Timothy H. Bell Stephen J. Burnett

London Health Sciences Center, Division of Orthopaedic Surgery,
University Campus, Room ADD Royal Jubilee Victoria Hospital,
Jim’s room, 339 Windermere Road, Victoria, BC, Canada
London, Ontario, Canada
Christophe Bussière
Jérôme Bérard Centre Orthopédique Médico-Chirurgical
Paediatric Orthopaedic Department, 71640 Dracy-le-Fort
CHU Lyon, Hôpital universitaire
Femme-Mère-Enfant de Lyon, Pieter Byn
Université Claude Bernard Lyon 1 AZ Maria Middelares Gent,
59, boulevard Pinel, 69677 Bron, France Kortrijksesteenweg 1028,
9000 Gent, Belgium
Daniel J. Berry
Department of Orthopeadic Surgery James R Carmichael
Mayo Clinic, 200 First Street SW Consultant orthopaedic surgeon
Rochester, Minnesota, USA Peterborough and Stamford Hospitals
NHS Foundation Trust UK
Aaron J. Bigham
Division of Orthopaedic Surgery, David Carmody
London Health Sciences Centre, Level 2/445 Victoria Ave,
339 Windermere Road, Chatswood 2067 NSW Australia
London, ON, Canada
Yannick Carrillon
Davide Edoardo Bonasia Centre Orthopédique Santy,
University of Iowa Sports Medicine, 24, avenue Paul Santy, 69008 Lyon, France
Via Lamarmora 26,
Torino, 10128, Italy Yves Catonné
Orthopaedic Department
Jean-Paul Bonvarlet Hôpital de la Pitié-Salpétrière
Institut Nollet, 23 rue Brochant, 47-83 boulevard de l’Hôpital
75017 Paris, France 75651 Paris, France
M. Bonnin
Centre Orthopédique Santy, P. Chambat
24, avenue Paul Santy, Centre Orthopédique Santy,
69008 Lyon, France 24 Av Paul Santy, 69008, Lyon, France

Robert Barry Bourne Le Roy Chong

London Health Sciences Centre, Department of Diagnostic Radiology,
University Hospital, London, Ontario, Canada Changi General Hospital, No 2,
Simei Street 3, 529889, Singapore
Jean Brilhault
Université François Rabelais Tours, Franck Chotel
CHRU Tours, France Paediatric Orthopaedic Department,
CHU Lyon, Hôpital universitaire Femme-Mère-
Robert H. Brophy Enfant de Lyon,
Department of Orthopaedic Surgery, Université Claude Bernard Lyon 1,
14532 South Outer Forty Drive, 59, boulevard Pinel,
field, MO 63017 69677 Bron, France

Robert T. Burks Mark Clatworthy

University of Utah Orthopaedic Center, Middlemore Hospital
590 Wakara Way, Auckland, New Zealand
Salt Lake City Utah 84108
Neil Clerk
Philippe Burdin Fowler Kennedy Sport Medicine Centre,
Université François Rabelais Tours, 3M Centre, University Of Western Ontario,
CHRU Tours, France London, Ontario, Canada N6A 3K7
List of Contributors VII

Brian J. Cole Natasa Devic

Departments of Orthopedics & Anatomy Imperial College London, Biomechanics
and Cell Biology Section, Mechanical Engineering Department,
Division of Sports Medicine South Kensington Campus, Exhibition Road,
Section Head, Cartilage Restoration Center at London SW7 2AZ
Rush Rush University Medical Center,
Department of Orthopedic Surgery, Karolien Didden
1611 W Harrison, Suite 300 Chicago, Universitaire Ziekenhuizen KU Leuven,
IL 60612, USA Weligerveld 1, 3212 Pellenberg, Belgium
ff Corten Patrick Djian
Department of Orthopaedics, Educational Secretary of the European Society
University hospitals Leuven, of Sports Traumatology, Knee surgery and
Herestraat 49 B-3000 Leuven Arthroscopy (ESSKA)
23, avenue Niel
Angela Deakin 75017 Paris, France
Golden Jubilee National Hospital,
Beardmore Street, Clydebank,
G81 4HX Glasgow UK Simon Donell
Institute of Orthopaedics,
Michael J. DeFranco Norfolk & Norwich University Hospital, UK
Rush University Medical Center,
Department of Orthopedic Surgery, Michael Dunbar
1725 West Harrison Street, Division of Orthopaedic Surgery, Dalhousie
Suite 1063, Chicago, IL 60612 University, 1796 Summer Street Suite# 4822,
QEII Health Sciences Centre,
David Dejour Halifax NS, Canada
8 Avenue Ben Gourion, Craig J. Edson
Lyon 69009, France GHS Orthopaedics Woodbine
Danville, PA, USA
Marco Delcogliano
Department of Orthopedic and Sports Andrew Edwards
Trauma, Rizzoli Orthopaedic Institute, 39 New Road
Bologna, Italy Wonersh Guildford
Surrey GU5 0SF
Craig J. Della Valle
Associate Professor of Orthopaedic Surgery, Evan D. Ellis
Rush University Medical Center, Department of Orthopaedic Surgery,
Chicago, IL 60612 Washington University, St. Louis, MO
Douglas A. Dennis Lars Engebretsen
Department of Biomedical Engineering, Department of Orthopaedic Surgery
University of Tennessee, Rocky Mountain Oslo University Hospital and Faculty
Musculoskeletal Research Laboratory, of Medicine University of Oslo, Norway
Denver, Colorado
Patrick Deprez Gregory C. Fanelli
Orthopaedic Department, A.Z. St-Lucas, 115 Woodbine Lane, Danville,
St-Lucaslaan 29, 8310 Brugge, Belgium PA 17822-5212, USA

Jacques Desnoyer Lutul D. Farrow

Orthopaedic Clinic Charles LeMoyne Department of Orthopaedic Surgery,
126, rue Saint-Louis LeMoyne, Cleveland Clinic, Cleveland, Ohio, USA
QC Canada
Giuseppe Filardo
Gérard Deschamps Department of Orthopedic and Sports
Centre Orthopédique Médico-Chirurgical Trauma, Rizzoli Orthopaedic Institute,
71640 Dracy-le-Fort Bologna, Italy
VIII The Knee Joint

P. Filippini Ronald P. Grelsamer

University Paris XII APHP-Hôpital Department of Orthopedic Surgery,
Henri Mondor, 94010 Créteil, France The Mount Sinai Medical Center,
New York
Donald C. Fithian
Department of Surgical Outcomes Chad J. Griffith
and Analysis, 3033 Bunker Hill Street, Department of Orthopaedic Surgery,
San Diego, CA 92109 University of Minnesota, 2450 Riverside
Avenue, R200, Minneapolis, MN 55454
Brian Forsythe
Department of Orthopaedic Surgery, Allan Gross
University of Pittsburgh Medical Center, Mt Sinai Hospital
Pittsburgh Toronto, Canada
Arlen D. Hanssen
Peter J. Fowler Mayo Clinic,
Schulich School of Medicine & Dentistry, Rochester, Minnesota
University Of Western Ontario, Fowler
Kennedy Sport Medicine Centre, Christopher D. Harner
3M Centre, London, Ontario, Department of Orthopaedic Surgery,
Canada N6A 3K7 University of Pittsburgh School of Medicine,
Freddie H. Fu
Department of Orthopaedic Surgery Yves Hémon
University of Pittsburgh Department of Orthopedic Surgery
3471 Fifth Avenue Aix-Marseille University
Kaufman Building, Suite 1011 Hopital Sainte-Marguerite
Pittsburgh, PA 15213, USA Marseille, France
Donald S. Garbuz Julien Henry
Department of Orthopaedics, University Orthopaedic traumatology and Sport
of British Columbia, 3114-910 West 10th Medecine Department
Avenue, Vancouver, BC V5Z 4E3, Hôpital Jules Courmont, CHU Lyon
Canada 69495 Pierre Bénite
J Robert Giffin
Schulich School of Medicine & Dentistry, Philippe Hernigou
University Of Western Ontario, University Paris XII APHP-Hôpital
Fowler Kennedy Sports Medicine Centre, Henri Mondor – 94010 Créteil- France
London, Ontario, Canada N6A 3K7
Timothy E. Hewett, FACSM
Giovanni Giordano Departments of Physiology and Cell Biology,
Department of Orthopedic and Sports Orthopaedic Surgery, Family Medicine,
Trauma, Rizzoli Orthopaedic Institute, Biomedical Engineering & Allied Medicine
Bologna, Italy The Ohio State University
2050 Kenny Road, Suite 3100
Columbus, OH 43221-3502
Jason Gould Departments of Pediatrics and Orthopaedic
Department of Orthopedic Surgery, Surgery, University of Cincinnati College
The Mount Sinai Medical Center, of Medicine, 3333 Burnet Avenue, MLC
New York 10001, Cincinnati, OH 45229-3039
Edward James Graham Benton E. Heyworth
London Health Sciences Centre, Orthopaedic Surgery Resident, Hospital
University Hospital, London, Ontario for Special Surgery, 535 East 70th Street,
New York, NY 10021
Alberto Gregori
Hairmyres Eaglesham Road, Jürgen Höher
G75 8RG Glasgow, UK Clinic for Sports Medicine und Arthroscopy
List of Contributors IX

at Cologne Merheim Medical Center Tim Kostamo

University of Witten-Herdecke Department of Orthopaedics
Cologne, Germany 3825 Sunset Street
Burnaby, BC V5G 1T4
James L. Howard Canada
Division of Orthopaedic Surgery,
London Health Sciences Centre, Tron Krosshaug
339 Windermere Road, London, ON, Canada Oslo Sports Trauma Research Center,
Norwegian School of Sport Sciences,
William J. Hozack PB 4014 Ullevål Stadion, 0806 Oslo, Norway
Rothman Institute at Thomas Jefffferson
University, 925 Chestnut Street, 5th Floor, Matthias Kusma
Philadelphia, PA 19107, USA Department of Orthopaedic Surgery,
University Hospital, Saarland University,
Junji Iwasa Homburg/Saar, Germany
Orthopaedic Center, Ullevaal University
Hospital and Medical School, Oslo, Norway Robert F. LaPrade
The Steadman Clinic
ffrey D. Jackson Biomechanics Research Department - Steadman
Department of Orthopedic Surgery, Philippon Research Institute
Mayo Clinic, 200 First Street, 181 W. Meadow Drive
SW, Rochester, MN 55905 Suite 1000 Vail,
Colorado 81657, USA
Redouane Jalil
University Paris XII APHP-Hôpital Leonard C. Latt
Henri Mondor, 94010 Créteil- France Duke University Medical Center, Box 3000,
Durham, NC 27710
Bret T. Kean
Thomas Laumonier
University of Utah Orthopaedic Center,
Unité d’orthopédie et traumatologie du sport,
590 Wakara Way, Service de chirurgie orthopédique
Salt Lake City Utah 84108 et traumatologie de l’appareil moteur,
Hôpitaux Universitaires de Genève,
Frédéric Khiami 24, rue Micheli-du-Crest,
Orthopaedic Department CH-1211 Genève 14, Suisse
Hôpital de la Pitié-Salpétrière
47- 83, boulevard de l’Hôpital Jean Raphael Laurent
75651 Paris, France Orthopaedic Surgery
10A, rue du Bourdeau
Sung-Jae Kim 7542 Mont-Saint-Aubert, France
Department of Orthopaedic Surgery
and the Arthroscopy & Joint Research Frédéric Lavoie
Institute, Yonsei University Health System, Service de Chirurgie Orthopédique,
Seoul, Korea Hôpital Notre-Dame, Centre Hospitalier
Universitaire de Montréal, 1560 Sherbrooke
Raymond H. Kim Est, local DR 1118-16, Montréal, Canada
Colorado Joint Replacement, Denver, Colorado
Vincent Leclercq
Richard Kjar Prosthesis design and manufacturing
42 Green St, Wangaratta, VIC 3677, Australia Symbios Orthopaedic SA
Dieter Kohn Pierre-François Leyvraz
Department of Orthopaedic Surgery, Département appareil locomoteur
University Hospital, Saarland University, Hôpital orthopédique CHUV
Homburg/Saar, Germany CH-1011 Lausanne, Suisse
Elizaveta Kon Philipp Lobenhoffer
Department of Orthopedic and Sports Trauma, DK Henriettenstiftung Hannover,
Rizzoli Orthopaedic Institute, Bologna, Italy D-30171 Hannover, Marienstrasse 72-90
X The Knee Joint

David Longino Matthew. J. Matava

Fowler Kennedy Sport Medicine Centre, Washington University Department
3M Centre, University Of Western Ontario, of Orthopaedic Surgery, St. Louis, MO
London, Ontario, Canada N6A 3K7
David R. McAllister
Sébastien Lustig Sports Medicine Service
Service de Chirurgie Orthopédique David Geff
ffen School of Medicine at UCLA
Centre Albert-Trillat, Hospital Department of Orthopaedic Surgery
de la Croix-Rousse, Los Angeles, CA 90095-6902
8, rue de Margnolles
69300 Caluire, Lyon, France James McAuley
London Health Sciences Center, University
Tad M. Mabry Campus, Room ADD, 339 Windermere Road,
Mayo Clinic, Rochester, Minnesota London, Ontario, Canada

Steven J. MacDonald Richard W. McCalden

University Hospital, London, Ontario, University of Western Ontario,
Canada Division of Orthopaedic Surgery,
London Health Science Centre,
Maurilio Marcacci London, Ontario, Canada
Department of Orthopedic and Sports
Allison G. McNickle
Trauma, Rizzoli Orthopaedic Institute,
Rush University Medical Center,
Bologna, Italy
Department of Orthopedic Surgery,
1725 West Harrison Street, Suite 1063,
Giulio M. Marcheggiani Muccioli Chicago, IL 60612
Department of Orthopedic and Sports
Trauma, Rizzoli Orthopaedic Institute, Jacques Ménétrey
Bologna, Italy Unité d’orthopédie et traumatologie du sport
(UOTS), Service de chirurgie orthopédique
Fabrizio Margheritini et traumatologie de l’appareil moteur,
Department of Health Science, Unit of Sports University Hospital of Geneva, Rue Gabrielle-
Traumatology, Piazza Lauro de Bosis 6, Perret-Gentil 4, 1211 Geneva 14
00199, Rome, Italy
Guy Messerli
Pier Paulo Mariani Unité d’orthopédie et traumatologie du sport
Department of Health Science, Unit of Sports (UOTS), Service de chirurgie orthopédique
Traumatology, Piazza Lauro de Bosis 6, et traumatologie de l’appareil moteur,
00199, Rome, University Hospital of Geneva,
Italy Rue Gabrielle-Perret-Gentil 4,
1211 Geneva 14
Robert G. Marx
Foster Center for Clinical Outcome Research, Anthony Miniaci
Hospital for Special Surgery, 535 East CCLCM
70th Street, New York, NY 10021 Cleveland Clinic
Weill Medical College of Cornell University, 5555 Transportation Blvd.
New York, NY Garfi
field Heights, OH 44125, USA
Randy Mascarenhas Bernard Moyen
Department of Orthopaedic Surgery, Orthopaedic Surgery
University of Pittsburgh School of Medicine, Centre Hospitalier Lyon-Sud
Pittsburgh Chemin du Grand Revoyet
69495 Pierre-Bénite
Bassam A. Masri France
Department of Orthopaedics,
University of British Columbia, M. Mukisi Mukasa
3114-910 West 10th Avenue, University Paris XII APHP-Hôpital
Vancouver, BC V5Z 4E3, Canada Henri Mondor, 94010 Créteil, France
List of Contributors XI

Douglas D. R. Naudie Sebastien Parratte

London Health Sciences Center, Department of Orthopedic Surgery
University Campus, Room A9-028, Aix-Marseille University, Hopital
339 Windermere Road, London, Sainte-Marguerite, Marseille, France
Ontario, Canada
Frédéric Picard
John H. Newman Golden Jubilee National Hospital, Beardmore
Avon Orthopaedic Centre, Bristol, UK Street, Clydebank, G81 4HX Glasgow UK
Philippe Neyret Sergio R. Piedade
Service de Chirurgie Orthopédique, Professor, Department of Orthopedics
Centre Albert-Trillat, Hôpital de la Croix- and Traumatology, School of Medical Sciences,
Rousse, 8, rue de Margnolles, Exercise and Sport Medicine Group,
69300 Caluire, Lyon, State University of Campinas / UNICAMP
France Rua Tessália Vieira de Camargo n° 126
Cidade Universitaria Zeferino Vaz,
Jean-Yves Nordin 13083-887, Campinas/SP
Orthopaedic Surgery
Hôpital Bicêtre Alexandre Poignard
78, rue du Général Leclerc University Paris XII APHP-Hôpital
94270 Le Kremlin Bicêtre Henri Mondor, 94010 Créteil, France
Mathew W. Pombo
Fabio R. Orozco Department of Orthopaedic Surgery, University
Orthopedic Surgery of Pittsburgh Medical Center, Pittsburgh
2500 English Creek Avenue Building 1300
Egg Harbor Township, NJ 08234 Hollis G. Potter
Weil Medical College of Cornell University,
S. Ostermeier 535 East 70th Street, New York, NY 10021
Orthopaedic Department
Hannover Medical School Jean Louis Prudhon
Anna-von-Borries-Str. 1-7 College of Orthopaedics,
30625 Hannover, Germany Clinique des Cedres-Echirolles
48, avenue de Grugliasco
Mark W. Pagnano 38130 Echirolles, France
Department of Orthopedic Surgery,
Mayo Clinic, 200 First Street, SW, Giancarlo Puddu
Rochester, MN 55905 Clinica Valle Giulia, Via De Notaris 2b,
00197 Roma, Italy
Ludovico Panarella
Clinica Valle Giulia, Via De Notaris 2b, Bénédicte Quelard
00197 Roma, Italy Centre Orthopédique Santy, 24, avenue Paul
Santy, 69008, Lyon, France
Jean Claude Panisset
College of Orthopaedics, Clinique Olivier Rachet
des Cédres-Grenoble Centre Hospitalier Publique d’Hauteville,
48, avenue de Grugliasco 01 110 Hauteville, France
38130 Echirolles, France
Kian Raiszadeh
Dietrich Pape 400 Craven Road, San Marcos, CA 92078,
Department of Orthopaedic and Trauma USA
Surgery, Centre for Sports and Preventive
Medicine, Centre Hospitalier de Luxembourg- Amar S. Ranawat
Clinique d’Eich, 78, rte. d’Eich, Hospital for Special Surgery
L-1460 Luxembourg 535 East 70th St, 6th Floor
New York, NY 10021, USA
Richard D. Parker
Cleveland Clinic Sports Health, Anil. S. Ranawat
Cleveland Clinic Foundation, Cleveland, Ohio Hospital for Special Surgery
XII The Knee Joint

535 East 70th St, 6th Floor 125 Parker Hill Ave Ste 560
New York, NY 10021, USA Boston, MA
Chitranjan S. Ranawat Romain Seil
Hospital for Special Surgery Department of Orthopaedic and Trauma
535 East 70th St, 6th Floor Surgery, Centre for Sports and Preventive
New York, NY 10021, USA Medicine, Centre Hospitalier de Luxembourg-
Clinique d’Eich, 78, rte. d’Eich,
Corey J. Richards L-1460 Luxembourg
Department of Orthopaedics,
University of British Columbia, Elvire Servien
3114-910 West 10th Avenue, Service de Chirurgie Orthopédique,
Vancouver, BC V5Z 4E3, Canada Centre Albert-Trillat, Hôpital de la Croix-
Rousse, 8, rue de Margnolles,
James R. Robinson 69300 Caluire, Lyon, France
Avon Orthopaedic Centre,
Southmead Hospital, Michael A. Shaff ffer
Westbury-on-Trym, Bristol. Department of Rehabilitation Therapies,
BS10 5NB, UK 0733 JPP, University of Iowa Hospitals
and Clinics, Iowa City, IA 52242
Samuel P. Robinson
Department of Orthopaedics, Sven Shafifizadeh
University of Pittsburgh, Department for Orthopedics
3200 South Water Street, and Trauma Surgery
Pittsburgh, PA 15213 Cologne Merheim Medical Center
University of Witten-Herdecke Cologne,
Sérgio Rocha Piedade Germany
Department of Orthopedics and Traumatology, Wei Shen
School of Medical Sciences, Exercise and Sport Department of Orthopaedics, University
Medicine Group, State University of Campinas, of Pittsburgh, 3200 South Water Street,
CEP 13081-970 Campinas, Sao Paulo, Brasil Pittsburgh, PA 15213
James R. Robinson Yosuke Shima
Orthopaedic Surgery Orthopaedic Center, Ullevaal University
Nuffiffield Health Bristol Hospital Hospital and Medical School, Oslo, Norway
Upper Byron Place
Clifton Bristol BS8 1JU UK Darryl B. Sneag,
Fourth-year Medical Student
Aaron G. Rosenberg Albert Einstein College of Medicine,
Rush University Medical Center, 1725 West Yeshiva University
Harrison Street, Suite 1063, Chicago, IL 60612
Bertrand Sonnery-Cottet
Alexander P. Sah Centre Orthopédique Santy,
Rush University Medical Center, 1725 West 24 Av Paul Santy, 69008 Lyon, France
Harrison Street, Suite 1063,
Chicago, IL 60612 Sankar Sripada
Trauma and Orthopaedics, Ninewells Hospital
Elhadi Sariali and Medical School, Dundee DD1 9SY,
Orthopaedic Department Scotland, UK
Hôpital de la Pitié-Salpétrière
47-83 boulevard de l’Hôpital Christina Stukenborg-Colsman
75651 Paris, France Orthopaedic Department
Hannover Medical School
Sven Scheffl
ffler Anna-von-Borries-Str. 1-7
Center for Musculoskeletal Surgery, Charité, 30625 Hannover Germany
University Medicine Berlin, Germany
Michael Tanzer
Richard D. Scott Division of Orthopaedic Surgery, McGill
New England Baptist Hospital University, Montreal, Quebec, Canada
List of Contributors XIII

Neil Thomas Hôpital universitaire de Genève

Consultant Orthopaedic Surgeon 24, rue Micheli-du-Crest
BMI The Hampshire Clinic UK 1211 Genève 14
Bruno Tillie
Orthopaedic Surgery Rene Verdonk
Clinique Bon Secours Knee Surgery & Sports Traumatology
2, rue du Docteur Forgeois Department of Orthopaedic Surgery
62000 Arras Ghent University Hospital
Harukazu Tohyama
Department of Sports Medicine and Joint Peter Verdonk
Reconstruction Surgery Hokkaido Knee Surgery & Sports Traumatology
University School of Medicine, Sapporo, Japan Department of Orthopaedic Surgery
Ghent University Hospital and Stedelijk
Geert Van Damme Ziekenhuis Roeselare Belgium
Department of Orthopaedic Surgery
AZ Sint Lucas, Sint Lucaslaan 29 Jan Victor
8310, Brugge, Belgium Orthopaedic Department, A.Z. St-Lucas,
St-Lucaslaan 29, 8310 Brugge, Belgium
Pieter Vansintjan
Department of Orthopaedic Surgery, Coen A. Wijdicks
Ghent University Hospital, Biomechanics Research Department
Ghent, Belgium Steadman Philippon Resarch Institute
181 West Weadow Drive,
Ronald J van Heerwaarden Suite 1000 Vail, CO 81657, USA
Limb Deformity Reconstruction Unit, Depart-
ment of Orthopaedics Sint Maartenskliniek Philippe Wilmes
Woerden, Polanerbaan 2, 3447 GN Woerden, Department of Orthopaedic and Trauma Sur-
The Netherlands gery, Centre for Sports
and Preventive Medicine,
Johan Vanlauwe Centre Hospitalier de Luxembourg-Clinique
Department of Orthopaedics, University d’Eich, 78, rte. d’Eich,
hospitals Leuven, Herestraat 49 B-3000 L-1460 Luxembourg
H. Windhagen
Hilde Vandenneucker Orthopaedic Department
Department of Orthopaedics, Hannover Medical School
University hospitals Leuven, Anna-von-Borries-Str. 1-7
Herestraat 49 B-3000 Leuven, Belgium 30625 Hannover
Chris M. van den Broek
Department of Orthopaedics, Sint Maartensk- Andy Williams
liniek, PO Box 9011 6500 GM Nijmegen, Department of Orthopaedic Surgery,
The Netherlands Chelsea and Westminster Hospital,
369 Fulham Road,
Gijs G. van Hellemondt London SW10 9NH
Department of Orthopaedics, Sint Maartensk-
liniek, PO Box 9011 6500 GM Nijmegen, Glenn N. Williams
The Netherlands Graduate Program in Physical Therapy
and Rehabilitation Science,
Ramiro Vargas Medical Education Building,
Centre Orthopédique Santy, University of Iowa, Iowa
24 Av Paul Santy, 69008 Lyon, France
Rick W. Wright
Florence Unno-Veith Washington University Department
Clinique et polyclinique of Orthopaedic Surgery,
d’orthopédie de l’appareil moteur St. Louis, MO
XIV The Knee Joint

Thomas Y. Wu Rachad Zayni

Department of Orthopaedic Surgery, Centre Orthopédique Santy
Ventura County Medical Center, 24 Av Paul Santy
Ventura, California, USA 69008 Lyon, France

Ate B. Wymenga Bohdanna T. Zazulak

Department of Orthopaedics, Sint Maartensk- DPT, MS, OCS
liniek, PO Box 9011 6500 GM Nijmegen, Yale New Haven Hospital
The Netherlands Department of Orthopaedics
and Rehabilitation
Kazunori Yasuda 20 York Street
Department of Sports Medicine and Joint New Haven, Connecticut 06510, USA
Reconstruction Surgery, Hokkaido Yale University School of Medicine
University School of Medicine, Sapporo, Department of Orthopaedics
Japan Yale Physician’s Building
800 Howard Avenue
Stefano Zaffffagnini New Haven, Connecticut 06510, USA
Department of Orthopedic and Sports Trauma,
Rizzoli Orthopaedic Institute, Bologna, Sébastien Zilber
Italy University Paris XII APHP-Hôpital
Henri Mondor, 94010 Créteil, France
Table of Contents

Foreword ........................................................................................ XXI

I The Traumatic Knee ..................................................................... 1

Basic Sciences ............................................................................................ 3
1. The menisci: anatomy, healing response, and biomechanics
A. Amendola, D. E. Bonasia....................................................................................... 5
2. The cruciate ligaments: anatomy, biology, and biomechanics
S. Scheffl
ffler .............................................................................................................. 11
3. The anatomy and biomechanics of the medial collateral ligament
and posteromedial corner of the knee
A. A. Amis, J. R. Robinson ........................................................................................ 23
4. The lateral collateral ligament and posterolateral corner
C. J. Griffi
ffith, C. A. Wijdicks, R. F. LaPrade ............................................................... 31
5. Basic science of ligament healing
H. Tohyama, K. Yasuda ............................................................................................. 43
Clinical Basis ............................................................................................. 51
6. Clinical basis: epidemiology, risk factors,
mechanisms of injury, and prevention
of ligament injuries of the knee
T. E. Hewett, B. T. Zazulak, T. Krosshaug, R. Bahr ................................................... 53
7. MRI evaluation of knee ligaments
H. G. Potter, D. B. Sneag, L. R. Chong ....................................................................... 71
8. Classifi
fication of knee laxities
S. R. Piedade, E. Servien, F. Lavoie, P. Neyret ........................................................... 85
9. Scoring the knee
B. E. Heyworth, R. H. Brophy, R. G. Marx ................................................................ 95
The Menisci ............................................................................................... 107
10. Arthroscopic meniscectomy
J. C. Panisset, J. L. Prudhon...................................................................................... 109
11. Meniscal sutures
P. Wilmes, D. Pape, R. Seil ......................................................................................... 125
12. Meniscal allograft transplantation
P. Verdonk, P. Vansintjan, R. Verdonk ....................................................................... 139
The ACL ..................................................................................................... 149
13. Diagnostic and surgical decision ACL tears
B. T. Kean, R. T. Burks .............................................................................................. 151
14. Natural history of ACL tears: from rupture to osteoarthritis
M. J. Matava, R. W. Wright, E. D. Ellis ..................................................................... 163
XVI The Knee Joint

15. Graft choice in ACL reconstruction

D. E. Bonasia, A. Amendola....................................................................................... 173
16. Tunnels, graft positioning, and isometry in ACL reconstruction
A. Williams, N. Devic ................................................................................................ 183
17. Technique in ACL reconstruction: hamstring reconstruction
D. Longino, N. Clerk, P. J. Fowler, J. R. Giffin
ffi ........................................................... 195
18. Technique in ACL reconstruction: patellar tendon
D. R. McAllister, T. Y. Wu .......................................................................................... 203
19. Place of navigation in anterior cruciate ligament reconstruction
G. Messerli, J. Ménétrey ........................................................................................... 217
20. Single or double bundle?
B. Sonnery-Cottet ..................................................................................................... 227
21. Anatomic double-bundle ACL reconstruction: how I do it?
K. Yasuda .................................................................................................................. 235
22. Results of ACL reconstruction
J. Iwasa, Y. Shima, L. Engebretsen ............................................................................ 245
23. Arthrofi
fibrosis after anterior cruciate ligament reconstruction
P. Chambat, R. Vargas, J. Desnoyer........................................................................... 263
24. ACL rehabilitation
M. A. Shaffer,
ff G. N. Williams .................................................................................... 269
25. ACL rupture in children: anatomical and biological bases, outcome
of ACL defificient knee in childhood: strategy, operative technique, results,
and complications.
F. Chotel, J. Henry, J. Bérard .................................................................................... 291
26. Combined injuries of the anterior cruciate ligament
and posterolateral corner
S. P. Robinson, W. Shen, F. H. Fu ............................................................................... 325
27. Failure in ACL reconstruction: etiology, treatment, and results
N. Thomas, J. Carmichael ......................................................................................... 343
The PCL...................................................................................................... 355
28. Defi
finition and diagnosis of posterior cruciate ligament injury
and algorithm of treatment
J. Ménétrey ............................................................................................................... 357
29. Natural history of PCL ruptures
S. Akhavan, R. D. Parker ........................................................................................... 369
30. The PCL: difffferent options in PCL reconstruction:
choice of the graft? One or two bundles?
J. Höher, S. Shafizadeh
fi ............................................................................................. 377
31. Graft tunnel positioning during PCL reconstruction
A. A. Amis, A. Edwards, S. Apsingi ........................................................................... 387
32. Techniques in posterior cruciate ligament reconstruction:
an arthroscopic approach
B. Forsythe, R. Mascarenhas, M. W. Pombo, C. D. Harner ........................................ 395
33. Arthroscopic reconstruction of the posterior cruciate ligament
using double-bundle and tibial-inlay technique
S.- J. Kim .................................................................................................................. 405
34. Technique in PCL reconstruction: mini posterior approach
R. Badet, P. Verdonk, S. Rocha Piedade ..................................................................... 411
Table of Contents XVII

35. Results of PCL reconstruction

F. Margheritini, M. Aboelnour, P.P. Mariani .............................................................. 417
36. Combined injuries to the posterior cruciate ligament
and medial collateral ligament of the knee
B. Forsythe, R. Mascarenhas, M. W. Pombo, C. D. Harner ........................................ 421
37. PCL injury associated with a posterolateral tear
K. Corten, J. Bellemans ............................................................................................. 427
Bicruciate injuries and dislocations .......................................................... 441
38. The multiple-ligament injured knee
G. C. Fanelli, C. J. Edson .......................................................................................... 443
39. Surgical treatment of cartilage tear: principles and results
F. U. Veith, J. Ménétrey ............................................................................................ 457
40. Technique of mosaicplasty
A. Miniaci, L. D. Farrow ........................................................................................... 483
41. Allograft osteoarticular resurfacing
M. J. DeFranco, A. G. McNickle, B. J. Cole................................................................ 497
42. Technique of chondrocytes implantation
S. Zaff
ffagnini, E. Kon, G. Filardo, G. Giordano, M. Delcogliano,
G. M. Marcheggiani Muccioli, M. Marcacci ............................................................... 505
43. Regenerative medicine for cartilage
T. Laumonier, J. Ménétrey ........................................................................................ 511
Patello-femoral joint ................................................................................. 517
44. The biomechanics of the patella
R. P. Grelsamer, J. Gould ........................................................................................... 519
45. Imaging of patellofemoral joint
Y. Carrillon ................................................................................................................ 525
46. Anterior knee pain and patellar instability: diagnosis and treatment
K. F. Almqvist, E. A. Arendt ...................................................................................... 533
47. Patellar stabilization for episodic patellar instability
K. Raiszadeh, D. C. Fithian, L. D. Latt ...................................................................... 539
48. Deepening trochleoplasty for patellofemoral instability
D. Dejour, P. Byn ....................................................................................................... 549

II The Degenerative Knee ............................................................... 559

Osteoarthritis of the patello-femoral joint ............................................... 561
49. Patellofemoral osteoarthritis: pathophysiologie, treatment,
and results
H. Vandenneucker, K. Didden, J. Bellemans ............................................................. 563
50. Patellofemoral replacement
J. H. Newman ........................................................................................................... 573
Indications in osteoarthritis of the femoro-tibial joint ............................ 583
51. Is there a place for arthroscopy in the degenerative knee?
P. Djian, G. Bellier, B. Moyen, X. Ayral, J. P. Bonvarlet .............................................. 585
52. Surgical indications in medial knee osteoarthritis
F. Lavoie, S. Lustig, E. Servien, S. R. Piedade, P. Neyret............................................ 591
XVIII The Knee Joint

Osteotomy around the knee ...................................................................... 601

53. Biomechanics, basis, and indications of osteotomies around the knee
P. Hernigou, S. Zilber, A. Poignard, R. Jalil, P. Filippini, M. Mukisi Mukasa ............. 603
54. Technique of closing wedge HTO
D. Kohn, D. Pape ....................................................................................................... 611
55. Technique of open wedge HTO
P. Lobenhoff
ffer, J. D. Agneskirchner ........................................................................... 621
56. Results of HTO in medial OA of the knee
A. Amendola, D. E. Bonasia....................................................................................... 633
57. Osteotomies in the valgus knee
G. Puddu, L. Panarella .............................................................................................. 643
58. Medial closing wedge varus osteotomy of the distal femur
R. J. van Heerwaarden ............................................................................................. 653
Unicondylar knee arthroplasty ................................................................. 661
59. Technical considerations, results,
and complications of mobile-bearing UKA
R. W. McCalden ........................................................................................................ 663
60. Fixed bearing unicompartmental knee prosthesis:
results, complications, and technical considerations
G. Deschamps, C. Bussière, S. Donell ........................................................................ 669
61. Indications of unicompartmental knee arthroplasty
C. L. Barnes, R. D. Scott ............................................................................................ 685
62. Lateral Unicompartmental Knee Replacement
J. H. Newman ........................................................................................................... 689

III Primary Total Knee Arthroplasty............................................... 695

Design and concept in TKA ....................................................................... 697
63. The history of total knee arthroplasty
A. S. Ranawat, A, S. Ranawat, C. S. Ranawat .......................................................... 699
64. Posterostabilized TKA: advantages and disadvantages
S. Parratte, J.-M. Aubaniac, J.-N. A. Argenson ......................................................... 709
65. Conservation of posterior cruciate ligament
in fixed-bearing total knee replacement
J.Y. Nordin, Guepar Group ....................................................................................... 721
66. Deep dish TKA: advantages and disadvantages
P.-F. Leyvraz, V. Leclercq ........................................................................................... 729
67. Bicruciate retaining TKA: the future?
J. Bellemans, K. Corten, J. Vanlauwe, H. Vandenneucker ......................................... 735
68. Mobile-bearing total knee arthroplasty:
advantages and disadvantages
R. H. Kim, D. A. Dennis ............................................................................................ 741
69. Fixed-bearing total knee arthoplasty:
advantages and disadvantages
D. Kohn, M. Kusma ................................................................................................... 755
70. Cement fixation for total knee arthroplasty
J. D. Jackson, M. W. Pagnano.................................................................................... 759
Table of Contents XIX

Surgical techniques ................................................................................... 765

71. Pre-operative imaging techniques
in primary total knee replacement: role for computed tomography
P. Beaufi
fils.................................................................................................................. 767
72. The mini-subvastus approach for total knee arthroplasty
J. D. Jackson, M. W. Pagnano.................................................................................... 775
73. The degenerative knee – surgical techniques: “gap balancing”
C. Stukenborg-Colsman, S. Ostermeier, H. Windhagen ............................................ 783
74. Component orientation and total knee arthroplasty
F. R. Orozco, W. J. Hozack ......................................................................................... 791
75. Rotation of components in total knee arthroplasty
M. Bonnin ................................................................................................................. 797
76. Improving mobility
S. Parratte, A. Ashour, Y. Hémon, J.-M. Aubaniac, J.-N. Argenson ........................... 809
77. Medical management before and after TKA
E. J. Graham, R. B. Bourne ....................................................................................... 815
78. Rehabilitation protocol following total knee arthroplasty
B. Quelard, O. Rachet ............................................................................................... 823
The Patella in TKA ..................................................................................... 839
79. Why I always resurface the patella in TKA
K. Corten, S. J. MacDonald ....................................................................................... 841
80. Why I do not routinely resurface the patella in TKA
A. J. Bigham, J. L. Howard........................................................................................ 857
Navigation in TKA ..................................................................................... 865
81. Total knee replacement navigation: the different ff techniques
F. Picard, A. Gregori, A. Deakin................................................................................. 867
82. Why using navigation in total knee arthroplasty?
P. Deprez, J. Victor .................................................................................................... 879
Results in Primary TKA ............................................................................. 885
83. Results and function of total knee arthroplasty
M. Dunbar, S. Sripada, R. Kjar ................................................................................. 887
fficulties in Primary TKA ....................................................................... 895
84. TKA in the stiff
ff knee
J. Vanlauwe, H. Vandenneucker, J. Bellemans........................................................... 897
85. The lateral approach in the valgus knee
R. Zayni, M. Bonnin .................................................................................................. 901
86. TKA in the severe valgus knee: lateral epicondyle sliding osteotomy technique
J. Brilhault, P. Burdin................................................................................................ 907
87. Total knee replacement in patients with severe varus deformity
Y. Catonné, E. Sariali, F. Khiami, B. Tillie ................................................................. 915
88. Total knee arthroplasty after failed high tibial osteotomy
M. Bonnin, R. Zayni .................................................................................................. 923
89. Total knee arthroplasty after malunion
T. Ait Si Selmi, D. Carmody, Ph. Neyret .................................................................... 933
XX The Knee Joint

90. Revision total knee arthroplasty after failed unicompartmental knee replacement
J. R. Laurent ............................................................................................................. 941
Failures and Revision in TKA .................................................................... 953
91. Causes of failures in TKA
M. Bonnin ................................................................................................................. 955
92. The painful total knee arthroplasty
G. Van Damme, J. Victor ........................................................................................... 969
93. Pre-operative planning for revision TKA
E. J. Graham, S. J. MacDonald.................................................................................. 983
94. Technique of revision: surgical approach
M. Tanzer, S. Burnett................................................................................................ 989
95. Revision TKA: component removal
K. Corten, S. J. MacDonald ....................................................................................... 1003
96. Management of bony defects in revision TKR
M. Clatworthy .......................................................................................................... 1009
97. Stems in revision TKA
D. J. Berry ................................................................................................................. 1021
98. Technique of revision in TKA: joint line level
C. M. van den Broek, G. G. van Hellemondt, A. B. Wymenga .................................... 1029
99. Technique of revision in total knee arthroplasty: the patella
D. D. R. Naudie, T. H. Bell, J. McAuley...................................................................... 1039
100. Extensor mechanism allograft – surgical technique
A. P. Sah, C. J. Della Valle, A. G. Rosenberg .............................................................. 1049
101. Infection in total knee arthroplasty – prevention
T. Kostamo, S. J. MacDonald .................................................................................... 1057
102. Diagnosis of infection after total knee arthroplasty
C. J. Richards, D. S. Garbuz, B. A. Masri ................................................................... 1063
103. Infection in total knee arthroplasty: treatment
T. M. Mabry, A. D. Hanssen ...................................................................................... 1071

verything began when Johan Bellemans, Michel Bonnin, Jacques Ménétrey and I concluded the
1999 ISAKOS Congress in Washington, to anxiously begin our ESSKA-AOSSM Travelling Fellow-
ship. We travelled together visiting each of our host centers around the United States for almost a
month, where I enjoyed every day with my three fellows in my role as the “godfather”. During the next
part of our trip when guests of Peter Fowler, one of my best friends, at the University of Western Ontario
in London, Canada, we met Annunziato Amendola, a young “Italian” surgeon. More recently I met Steven
McDonald, a brilliant young Canadian surgeon.
Since normal locomotion is impossible without proper knee function and since numerous abnormalities
can interfere with normal function, the knee joint is our most frequently operated joint in the human
body. The expansion in knee treatment options and approaches introduce challenging problems to the
practicing surgeon and to the orthopaedic residents in training. Most important, this knowledge provides
the basis upon which an orthopaedist counsels a patient regarding the risks and benefi fits of every opera-
tive treatment. Actually many patients before or after the physician visit go into the internet to try to
understand if the suggestions of the treating surgeon are the same suggested by the “opinion leaders”.
They often get confused and frightened by the very diff fferent suggestions and proposals from diff fferent
orthopaedic surgeons. These patients have high expectations for overcoming their knee complaints and
ability to return to their previous activity level.
The text of this book is comprehensive and covers all surgical aspects of the knee pathology. Basic science,
epidemiology, imaging and surgical techniques are clearly reported and illustrated in a didactic fashion.
Despite the huge number of textbooks, journals and instructional courses dedicated to the knee, there
are still enormous areas of controversies within the orthopaedic community. This is why a multicontinen-
tal team of experts have been invited to defi fine and present their own vision and hands-on experience.
The book is divided in three parts: meniscal and ligamentous injuries, patello-femoral pathology and the
degenerative knee.
One lesson that can be drawn from this book is that none of us can accomplish much by ourselves and
that only through cooperation in groups and across national boundaries we can achieve real progress in
term of improved patient care.
For the future much remains to be improved and basic research needs to be further refined.
fi With its com-
prehensive, up-to-date summary of our knowledge of the knee, this book, thanks to the organization and
knowledge of the editors, will be a very valuable aid in furthering our understanding and management of
the “knee patient”.
Wishing a great success to the editors, I would like to report three quotations. TheTh first is from William
Harvey (1578-1657): “I would say with Fabricius, let all reasoning be silent when experience gainsays its
conclusion. The too familiar vice of the present age is to obtrude as manifest truths, mere fancies, born of
conjecture and superfi ficial reasoning, altogether unsupported by the testimony of sense.”
The second is from Robert Leach: “Enjoy the book, absorb the material so assiduously collected by the
editors and use that material to the benefi fit of your patients”. The third quotation is from my teacher
Jack C. Hughston: “To readers I would say, let the experience presented by this book speak for itself.”

Giancarlo Puddu, MD
Internationally Renowned Orthopaedic Surgeon
Inducted into Sports Medicine Hall of Fame
I The Traumatic Knee
Basic Sciences
Chapter 1

A. Amendola, D.E. Bonasia The menisci: anatomy, healing

response, and biomechanics

Introduction tion of extreme flexion and extension (8); (7) artic-

ular cartilage nutrition (12).

njury to the meniscus from both sports inju-
ries and daily living activities is common. As
a result, arthroscopic treatment of menis-
cal lesions has become one of the most common Anatomy
orthopaedic surgical procedures, with arthroscopic
partial meniscectomy as one of the top 10 ortho-
paedic surgical procedures performed in the United Gross features
States (1). Occurring isolated or associated with
ligamentous injuries, meniscal tears can result in In terms of gross anatomy, the menisci are
abnormal joint function and mechanics, leading to C-shaped or semicircular fibrocartilaginous struc-
subsequent degeneration of the joint. tures with bony attachments at the anterior and
In past years, there has been a significant
fi improve- posterior aspects of the tibial plateau (Fig. 1).
ment in the management of meniscal tears and The medial meniscus (MM) is C-shaped, with the
ficiency, with the acquired knowledge of the posterior horn larger than the anterior one. The Th
biomechanical importance of these structures in anterior horn attachment is variable, and this should
preserving articular cartilage and joint stability. be considered with meniscal transplantation and
In 1887, Sutton described the meniscus as “the anterior horn avulsions’reattachment (Fig. 2). Berlet
functionless remains of a leg muscle” (2). In 1948 and Fowler (13), in their anatomic study, described
Fairbanks stated that “meniscectomy is not wholly four types of anterior horn MM attachments. Th The
innocuous,” in his report of post-meniscectomy type IV variant has no firm bony attachment and is
radiographic changes (3). connected with the intermeniscal ligament or the
With respect to meniscal repair and healing, in soft tissues at the ACL insertion (Fig. 1). Nelson and
1883, Thomas Annandale (4) was the first to suture LaPrade (14) described similar type of attachment
a meniscal tear. In 1936, King (5) showed that in 14% of the cadavers examined; however, in the
degenerative changes appeared in a canine model majority of them, a firm anterior bony attachment
after meniscectomy and that peripheral menis- was observed. The posterior root of the MM attaches
cal tears could heal. In the 1950s and 1960s, the anterior to the insertion of the posterior cruciate
menisci were considered as unnecessary develop- ligament (PCL) and behind the medial tibial spine.
mental remnants and total meniscectomy was per- Johnson et al. (15) mapped the bony insertion sites
formed for almost any meniscal tear suspected on of the menisci, describing their location and surface
clinical examination. It took almost a century from area. The anterior horn of the MM has the largest
Annandale’s report until a conservative approach insertion area (61.4 mm2) and the posterior horn of
to the management of meniscal tears was applied the lateral meniscus (LM), the smallest (28.5 mm2).
clinically. In the last two decades, understand- The remainder of the MM is firmly attached to the
ing meniscal importance and the development of joint capsule and the surface of the deep medial cap-
arthroscopic techniques have improved meniscal sular ligament. Th
The capsular attachment of the MM
preservation and the healing response. on the tibial side is referred to as the coronary liga-
Currently, the main functions attributed to the ment. A thickening of the capsular attachment in the
menisci are (1) shock absorbing by dispersing midportion spans from the tibia to the femur and is
loads (6,7); (2) increasing congruity and contact referred to as the deep medial collateral ligament.
area between femur and tibia (8); (3) providing The LM has an almost circular shape. It covers a
joint stability (9); (4) protecting an anterior cru- larger portion of the tibial articular surface than
ciate ligament (ACL)-deficient
fi knee from arthritic does the MM (Fig. 1). Discoid LMs have been
changes (10); (5) proprioception (11); (6) limita- reported with an incidence of 3.5–5% (16). The
6 The Traumatic Knee

Fig. 2 – Medial (M) compartment, showing the concave shape of the medial tibial condyle
and the anterior and posterior horns of the medial meniscus. A: anterior aspect of the tibia,
P: posterior. The MRI picture demonstrates the concavity of the medial tibial plateau (white
Fig. 1 – Anatomical specimen of the tibial plateau with arrow).
the menisci. A: anterior aspect of the tibia, P: posterior, M:
medial meniscus, L: lateral meniscus compartment, ACL:
anterior cruciate ligament: note the anterior and posterior
horn attachments of the lateral meniscus adjacent to the
anterior cruciate ligament. The arrow shows the anterior
horn attachment of the medial meniscus may or may not
be attached to bone.

Fig. 3 – Lateral (L) compartment. Note that the anterior and

posterior horn attachments always attach to bone very close
together on either side of the tibial spine. The MRI picture
demonstrated the convex nature of the lateral tibial plateau.

anterior and posterior horns attach much closer to of the LM, where there is no firm peripheral attach-
each other than do those of the MM, making this ment to the femur and tibia. TheTh meniscal tears in
anatomical area very consistent and therefore easy this area are less likely to heal. Simonian et al. (17)
to maintain during meniscal transplantation. Th The investigated the role of the two popliteomeniscal
anterior horn of the LM and the ACL attach adja- fasciculi and showed that the disruption of both of
cent to each other and can be used as landmarks them may increase meniscal motion at the hiatus
for ACL reconstruction and meniscal transplanta- and cause hypermobility of the posterior horn of
tion (Fig. 3). Th
The posterior root is posterior to the the LM. Furthermore, Thompson et al. (18), with a
lateral tibial eminence. In Wrisberg’s variation of 3D MRI, demonstrated the greater mobility of the
discoid LM, the posterior horn bony attachment LM compared to the MM, through the knee range of
is absent, and the posterior meniscofemoral liga- motion. The excursion of the LM averaged 11.2 mm,
ment (of Wrisberg) is the only stabilizing structure. compared to 5.2 mm of the MM. This phenomenon
This type of insertion can result in posterior horn can be explained by the less rigorous attachments
instability, although a hypermobile meniscus may that the LM has to the articular capsule.
occur with a normal bony attachment. Th The anterior
meniscofemoral ligament (of Humphrey) runs from
the posterior horn of the LM anterior to the PCL Microscopic Features
and inserts on the femur. The popliteus tendon lies
posterior and lateral to the posterior root insertion Ultrastructurally, the meniscus is composed of
of the LM. The popliteal hiatus consists in a portion fibrochondrocytes that reside within and maintain
The menisci: anatomy, healing response, and biomechanics 7

the extracellular matrix, which is composed of col- been demonstrated to be similar to the vascular
lagen and various proteoglycans. This Th extracellular supply. The meniscal roots are the most richly
matrix gives the meniscus its biologic and material innervated, while the body’s innervation is mainly
properties that allow it to perform its load-bear- peripheral. Although not entirely clear, sensory
ing function. The collagen fibers (three layers) lie feedback and proprioception functions were
mostly along the longitudinal axis, with oblique hypothesized for these nerve endings. It seems
and radial fibers to enhance the structural integ- that the greatest feedback occurs at the extremes
rity (19). This orientation allows compressive loads of flexion and extension, when the horns are com-
to be dispersed by the circumferential fi fibers, while pressed and neural cells stimulated. Dye et al. (23),
the radial fibers act as tie fibers to resist longitudi- who did neurosensory mapping of the internal
nal tearing. Th
The surface fiber orientation is more of structures of the knee, confi firmed that probing
a mesh network or random confi figuration, thought peripheral tissues is more painful than central.
to be important in the distribution of shear stress.
The majority of collagen (90%) is type I, and
the remainder are types II, III, V, and VI. Elastin
accounts for approximately 0.6% of the dry weight Meniscal healing response
of the meniscus, and non-collagenous proteins, for
8–13% (20). The key factor in the process of tissue repair is
The fibrochondrocytes synthesize the fibrocar- accessibility of cells and infl
flammatory mediators to
tilaginous matrix and appear to be of two types, the site of injury. Th
The formation of a clot is an ini-
with the more superfi ficial cells being oval or fusi- tial phase that provides a scaffold
ff for matrix forma-
form and the deeper cells being more rounded. tion and is a chemotactic stimulus for the cellular
Both types contain abundant endoplasmic reticula elements that are involved in wound healing (24).
and Golgi complexes and few mitochondria. Therefore, tears in the vascular zone (red-red) tend
to form a clot and heal, whereas tears in the avas-
cular central region (white-white) do not. But the
most common tears and the dilemma occur when
Vascularity the lesion is in the red-white zone. Furthermore,
in this zone a significant
fi portion of the meniscus
At birth, the entire meniscus is vascular, but at 9 is usually involved. Th Therefore, in an attempt to
months, the inner one-third has become avascular. get these tears to heal every aspect of the process
This decrease in blood supply continues to age 10 is important: (1) technical suturing to provide a
years, when the meniscus closely resembles the stable repair; (2) post-operative cautious rehabili-
adult meniscus. Arnoczky and Warren (21) stud- tation and return to activity; and (3) stimulation
ied the adult vascularity of the menisci and dem- of the repair site by hematoma. Webber et al. (25)
onstrated that only the outer 10–25% of the LM showed in tissue culture that meniscal cells can pro-
and the outer 10–30% of the MM are vascular. Th The liferate and synthesize an extracellular matrix when
blood supply to the meniscus comes from the peri- exposed to factors that normally present in wound
meniscal capillary plexus, which arises from the hematoma. In order to promote healing, many
superior and inferior branches of the medial and authors investigated the use of a fibrin
fi clot, fibrin
lateral genicular arteries. A thin layer of synovium glue, cell growth factors, creating traumatic vascu-
extends a short distance over both the superior lar access channels, and adjacent synovial bleeding
and inferior surfaces of the menisci, without, how- by various methods. Currently, abrading the syn-
ever, contributing to the meniscal vascularity. At ovium adjacent to the tear, and “freshening up” the
the popliteal hiatus, the LM is relatively avascular. tear by rasps or shavers, is the common method of
Because of the avascular nature of the inner por- allowing hematoma’s formation (24). Although the
tion of the meniscus, cell nutrition is believed to real effi
fficacy of these procedures is unknown, we do
occur mainly through diff ffusion of synovial fluid know clinically the healing rate of meniscal tears is
(22). The menisci are historically divided in three higher in knees with concurrent ACL reconstruc-
zones (red-red, red-white, and white-white). The Th tion. This may indicate that hematoma formation
red-red zone consists of the outer third of the and bone marrow stimulation can promote menis-
meniscus and is vascular; the red-white zone rep- cal healing. In addition to stability of the joint and
resents the mid-third and receives nourishment the location of the tear, other factors that seem to
from both blood supply and synovial fluid;
fl and the positively aff
ffect healing include the acuity of the
white-white zone is considered totally avascular lesion, the young age of the patient, and a non-de-
and nourished by synovial fluid only. generative pattern of the tear (26,27).
The neuroanatomy of the meniscus is not totally In terms of rehabilitation, immobilization of the
clear, but the distribution of neural elements has knee seems to ultrastructurally decrease collagen
8 The Traumatic Knee

content in the meniscus, while knee motion tends reduced by 20% after meniscectomy. Th The menisci
to prevent collagen loss (28). Nevertheless, besides also showed an important function in providing
biology, the rehabilitation program should be joint stability (9). Medial meniscectomy in the
fi according to multiple factors: (1) tear pat- stable knee has little effffect on anteroposterior
tern; (2) stability of the tear and fixation;
fi (3) asso- motion, but in the ACL-defi ficient knee, it results
ciated procedures; (4) age and activity level of the in increased anterior tibial translation of up to
patient. 58% at 90° of flexion. Shoemaker and Markolf
(10) demonstrated that the posterior horn of the
MM is the most important structure resisting an
applied anterior tibial force in an ACL-deficient
Biomechanics knee. Allen et al. (35) showed that the resul-
tant force in the MM of the ACL-defi ficient knee
As previously mentioned, the menisci are impor- increased by 52% in full extension and by 197%
tant in many aspects of knee function, including at 60° of flexion under a 134-N load. Although
load sharing, shock absorption, reduction in joint the inner two-thirds of the meniscus is important
contact stresses, passive stabilization, increasing in maximizing joint contact area and increasing
congruity and contact area, limitation of extremes shock absorption, the integrity of the peripheral
of flexion and extension, and proprioception. The one-third is essential for both load transmission
findings of joint space narrowing, osteophyte for- and stability.
mation, and squaring of the femoral condyles after In summary, the menisci are important structures
total meniscectomy suggested that the meniscus is with significant
fi joint-protective properties. A clear
important in joint protection and led to investiga- understanding of the function, biology, and heal-
tions of the role of the meniscus in joint function. ing capacity of the meniscus is important to allow
The MM and the LM transmit respectively about proper decision making in the clinical setting.
50% and 70% of the load with the knee extended,
and this increases to 85% with the knee flexed
fl 90°
(6). Radin et al. (29) demonstrated that the loads References
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ficient knee. Eff
ffects of partial versus total
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ficient knee. J Orthop Res 18:109–115
Chapter 2

S. Scheffler The cruciate ligaments: anatomy,

biology, and biomechanics

Anatomy 16 weeks of gestation, and the organization of the

various ligamentous structures of the knee joint is

he first mentioning of the cruciate liga- completed shortly thereafter (5).
ments originates from an Egyptian papyrus During fetal development, both cruciate liga-
role dated around 3000 BC. Hippocrates ments are highly cellular with fibroblasts dis-
described the typical subluxation of the knee joint playing a distinct longitudinal orientation along
caused by cruciate ligament defi ficiency around the axis of tension. It is assumed that knee joint
460–370 BC. It is believed that Claudius Galen motion is guided from the beginning by both cru-
von Pergamen (129–199 BC) is responsible for the ciate ligaments and that they are a prerequisite
naming of the cruciate ligaments, calling them “lig- for proper development and maturation of the
ament genu cruciata.” In 1836, the Weber brothers femoral condyles and the tibial plateau. It was
from Goettingen, Germany, published a detailed observed that both cruciate ligaments already
analysis of the effffect of cruciate ligament insuf- have the capability of adapting their structural
ficiency on knee kinematics (1). The first English composition and orientation to the mechanical
detailed description of cruciate ligament anatomy, loading environment during fetal development.
biomechancis, and injury pattern was presented This allows for the development of the complex
by I. Palmer (2) in his thesis work and defined
fi the structure of the cruciate ligaments with their
positive anterior drawer phenomenon after ante- significant impact on knee joint kinematics.
rior cruciate ligament (ACL) injury.

Macroscopic anatomy
The ACL and the PCL are located at the center of the
Th knee starts to develop in the 4th week of gesta-
The human knee joint in the intercondylar fossa. Th The
tion with a recognizable structure around the 6th ACL extends from the anteromedial (AM) aspect
week in utero (3). The formation of the cruciate lig- of the tibia toward the posterolateral (PL) area of
aments has been observed as early as 6–8 weeks in the lateral femoral condyle (Fig. 1). The
Th PCL arises
fetal development (4,5). First, the posterior cruci- from the posterior tibia and moves anteromedially
ate ligament (PCL) can be distinguished before the behind the ACL to the lateral surface of the medial
initial development of the ACL (5). It is assumed femoral condyle (Fig. 2). Due to their anatomical
that the cruciate ligaments originate from either location, both cruciate ligaments allow for a com-
the fetal blastoma as a ventral condensation (6) plex functional interaction, providing translational
or as derivatives from the posterior portion of the and rotational stability to the human knee joint.
joint capsule (7). They develop from a concentra-
tion of synovial mesenchyme between the femoral
and tibial origins (8) and can be clearly separated Functional anatomy
from their surrounding tissue of the intermittent
joint zone (3). The ACL gradually moves into a more ACL
posterior location from the initial anterior location The ACL is a non-isometric structure that shows
in the knee joint as the intercondylar space forms signifi
ficant variations in its tension behavior
(6). The PCL does not change its location during throughout the cross section. Several authors
further fetal development (5). Both cruciate liga- described the ACL to be composed of differ- ff
ments remain coated by the synovial membrane, ent functional bands (Fig. 3). First Palmer (2)
therefore being extrasynovial in the intra-articular and later Girgis et al. (9) divided the ACL into a
environment (3). The organization of diff fferent smaller AM bundle and a larger PL bundle (10),
functional bundles of the ACL is clearly present at while Amis (11) and Hollis et al. (12) found three
12 The Traumatic Knee

Fig. 1 – (A, B) Illustration of ACL anatomy. Note the change in orientation of the anteromedial (straight line) and posterolateral bundle (dotted
line) at extension (1A) and flexion (1B). (Courtesy of Dr. Thore Zantop.)

Fig. 2 – View of the posteromedial aspect of the PCL outlining the artificially separated AL and
PM bundles. The tibial footprint in the facet between the medial and lateral posterior horns of
the menisci can be identified. (Courtesy of Andrew Amis, PhD)

Fig. 3 – Variations in the tibial attachment areas of the AM and PL bundle of the ACL. (Colom-
bet et al., Arthroscopyy 2006.)

fferent functional structures (AM, intermediate tion is lost and the femoral insertion site of the
band, PL). The simplifi fied two-bundle model has ACL becomes more horizontal, causing the AM to
become the most accepted model and a blueprint wrap around the PL bundle (Fig. 1B). Amis and
for anatomic ACL reconstruction. Both bundles Dawkins showed that in flexion beyond 90°, the
are non-isometric during the fl flexion-extension PL bundle retightens toward full flexion (11).
path of the knee joint. In knee extension, the
AM and PL bundles are parallel to each other, PCL
with the AM bundle being signifi ficantly longer Similarly to the ACL, the PCL does not consist
(34 mm) than the PL bundle (22.5 mm) (12; Fig. of a single functional unit but of two main fi fiber
1B). In extension the PL bundle is tight, while bundles, the anterolateral (AL) and posteromedial
the AM bundle is moderately loose. The highest (PM) (9,13,14; Fig. 2). However, other authors have
loads in the ACL were observed during anterior suggested that the PCL’s fiber anatomy and behav-
tibial loading near extension, which indicates the ior are more complex, describing the PCL as a fiber
necessity of a stronger PL bundle. Th The AM bundle continuum composed of up to four consistent geo-
lengthens and becomes tight in fl flexion, while the graphical fiber regions (15). Amis et al. described
PL bundle slackens toward flexion (12; Fig. 1A). this more a functional than an anatomical division
With increasing flflexion, the parallel fiber orienta- due to the difffferent tensioning behavior of the
The cruciate ligaments: anatomy, biology, and biomechanics 13

respective bundles during the arc of knee motion. attachment (11). As the ACL moves from its proxi-
The AL bundle has been found to be substantially mal insertion, its diameter increases and reaches
stronger and having a larger cross-sectional area its maximum as it inserts tibially (3,6). Th
The tibial
than the PM bundle (16). TheTh AL bundle is slack attachment of the ACL is located in front of and
and curved in the extended knee joint. With lateral to the medial intercondylar tubercle. Its
increasing flexion, the PCL lengthens and tight- lateral border is adjacent to the anterior horn and
ens, providing the dominating constraint to tibial can extend to the posterior horn of the lateral
posterior translation. The PM bundle is tight in meniscus. The width of the tibial attachment site
extension but, due to its proximodistal alignment, has been determined to range from 8 to 12 mm
resists hyperextension rather than posterior tibial and the anteroposterior length between 14 and
loading (13). During mid-flexion,
fl it moves past 21 mm (3,9,20,22). TheTh nomenclature AM and PL
the AL bundle anteriorly along the medial side of bundle derives from their anatomical insertion
the notch and becomes loose. In deep flexion,
fl PM in the tibial footprint of the ACL: the AM bundle
fibers are taut again and contribute to posterior inserts anteromedially and the PL bundle poste-
drawer stabilization (13,17). rolaterally. Colombet et al. (22) found large varia-
tions among the relative locations of the AM and
PL bundles in the tibial footprint. Even though
Insertion site anatomy the centers of the two fiber bundles lay antero-
posterior, the individual attachment areas of the
ACL AM and PL bundles were mediolaterally parallel to
The ACL is a dense collagenous structure with an each other and showed a large variation (Fig. 3)
irregular cross-sectional area that increases from compared to the very consistent femoral footprint
the femur to the tibia and changes with flexion
fl of the ACL.
and extension (18). At the attachment areas on the
femoral and tibial bone, the ACL fans out to 3.5 PCL
times the size of its mid-substance (19). The PCL is longer and stronger than the ACL (23).
The femoral attachment has been depicted on PCL footprints on the femur and the tibia are three
the inner surface of the lateral femoral condyle times larger than its mid-substance cross-sectional
at its posterior part (9,20). Girgis et al. described area (24).
the femoral insertion site as a vertically disposed The femoral insertion site of the PCL is located
semicircle (9), while Odensten (21) and Harner et at the medial femoral condyle and extends to the
al. (19) found it to be more of an oval than a round medial side of the femoral intercondylar notch.
shape. The
Th actual diameter of the insertion site In knee extension, the PCL forms a “half-moon”
shows significant
fi variation with the overall diam- shape against the articular cartilage of the medial
eter measuring from 11 to 24 mm (3,20). In a more femoral condyle (Fig. 4). The
Th area of the femoral
recent study by Colombet at al. (22), the proxim- attachment varies, sometimes extending poste-
odistal diameter of the femoral attachment of the riorly all the way to the posterior margin of the
ACL was measured to be 13.9 ± 9.5 mm, and the articular cartilage and proximally fanning out to
anteroposterior diameter 9.3 ± 7.1 mm. In exten- the roof of the intercondylar notch (13). In knee
sion, the fibers
fi of the AM bundle are located at the flexion, the much stronger AL bundle (16) covers
most anterior and proximal aspect of the femoral the area from the 12 to 3 o’clock position (right
insertion site, while the PL bundle fascicles origi- knee) and shows only little variations in its loca-
nate at the posterodistal area of the femoral ACL tion. The morphology of the PM bundle is more

Fig. 4 – Outline of the femoral footprint of the PCL.

(Courtesy of Dr. Freddie Fu)
14 The Traumatic Knee

variable, extending from the 3 o’clock position

toward variable locations on the posterior aspect Biology
of the medial femoral condyle. Often, menis-
cofemoral ligaments (MFLs) can be identified fi
in human knee joints (Fig. 5). Th The anterior MFL Microanatomy
of Humphrey attaches distal to the PCL on the The ACL and PCL microstructures follow the typi-
femur and becomes superfi ficial in deep flexion of cal organization of connective tissues found in
the knee joint (13). Care has to be taken not to human joints, even though characteristic differ- ff
mistake this structure as part of the PCL when ences between both cruciate ligaments exist.
performing PCL reconstruction and locating the Both cruciate ligaments are covered by a vascular
position of the femoral tunnel. Th The PCL fibers layer, termed “epiligament” (28,29), which is more
move posterodistally toward the posterior edge cellular and richer in sensory and proprioceptive
of the tibia in between the posterior horns of the nerves than the ligaments themselves. Below the
medial and lateral menisci. This area of attachment epiligament the typical fibrous
fi architecture of the
is called the PCL facet (9) and is distinct from the cruciate ligaments appears. These ligaments are
vertical posterior cortex. Its location is most con- hierarchically organized into groups of parallel
sistent among the insertion sites of the cruciate fibers, fascicles, which are surrounded by a connec-
ligaments, showing a predominately rectangular tive tissue called the paratenon. In the ACL, these
shape (25). It was found that the posterior fibers
fi fascicles have a size of 250 m to several millime-
blend with the periosteum and expand down the ters. The fascicles interdigitate and branch out to
posterior surface of the tibia for about 1.5–2 cm, connect superfi ficially with deeper layers of fascicles
with some fibers blending into the posterior cap- in the ligament (28). This is typically found at the
sule (24). The
Th AL fibers insert in the anteroproxi- femoral and tibial insertion sites. In the PCL, such
mal area of the tibial PCL footprint, covering the interdigitation is much more sparse with a homog-
entire flat intercondylar surface of the PCL facet enous strictly parallel orientation of the PCL fiber
(Fig. 2). They border the posterior edge of the bundles (28). The
Th fascicles can be further divided
root of the posterior horn of the medial meniscus into subfasciculi (100–250 m in diameter), which
(13,26) becoming more trapezoidal in shape. The Th are covered by an epitenon. Th The subfascicular units
PM fibers attach centrally at the posterior sur- (1–20 m) are composed of collagen fibrils, rang-
face of the tibia below the AL fibers. They extend ing between 20 and 155 nm in diameter for the
past the rim of the tibial plateau about 1.5 cm ACL and 20 and 180 nm for the PCL (28,30). The Th
postero-lateral-distally close to the attachment collagen fibrils
fi are part of a complex three-dimen-
area of the popliteus muscle. Some anatomical sional network of cellular components, such as
studies revealed posterior oblique fibers
fi of the fibroblasts and myofi fibroblasts that are submerged
PCL that might be confused with the posterior in an extracellular matrix, providing the environ-
MFL of Wrisberg (27). Th These fibers are situated ment for a sound mechanical and biological func-
posteriorly on the PCL moving from the medial tion of the cruciate ligaments. Furthermore, both
femoral condyle to the lateral facet of the tibia, cruciate ligaments display a characteristic direct
where they insert to the bone below the posterior type of insertion to the femoral and tibial bone.
horn of the lateral meniscus. This direct insertion consists of a transition from
ligamentous tissue via a zone of fibrocartilage and
mineralized cartilage to bone (31).

Cellular components
Most of the current knowledge on cellular compo-
sition of cruciate ligaments is based on analyses of
the ACL, with little information available on the
PCL. The local cells found in both cruciate ligaments
are fibroblasts. In the ACL, a typical distribution
from proximal to distal can be found (32,33). In
both ligaments, a subform of fibroblasts
fi has been
fied that exhibits contractile properties, the
so-called myofibroblasts.
fi Their specifi
fic function in
cruciate ligaments is not fully understood, but it is
Fig. 5 – Posterior view of PCL anatomy and the posterior meniscofemoral assumed that they play a role in the regular crimp
ligament of Wrisberg. (Courtesy of Dr. Thore Zantop.) formation and in the healing ligament (33,34).
The cruciate ligaments: anatomy, biology, and biomechanics 15

Murray et al. described the fibroblast distribution distal 60 nm). Similarily, Neurath et al. also found
in the AM bundle of the ACL (33). They depicted that the average fibril diameter of the ACL (74 nm)
a proximal part about one-fourth of the overall was below that of the PCL (82 nm) (28). In both
length that was highly cellular with round and ligaments, fibrils are organized into parallel and
ovoid cells next to parallel-oriented fusiform cells. dense structures that follow a regular wave pat-
The distal three-fourths of ACL were dominated tern, the so-called crimp, which is planar centrally
by spheroid cell at a much lower cell density and and helical at the periphery of the ligaments. TheTh
a shorter crimp formation. Duthon et al. (32) also crimp pattern represents the unique ability of the
observed signifi
ficant histological diff
fferences along cruciate ligaments to allow for continuous recruit-
the ACL, but distinguished a middle part from a ment of load-carrying collagen fi fibrils, therefore
proximal and distal part. The middle part was less functioning as a buffer
ff or shock absorber, so that
cellular than the proximal and contained fusiform longitudinal stretch of the ligament does not lead
and spindle-shaped fibroblasts and a special zone to immediate, irreversible fibrous damage.
of cartilage and fibrocartilage, especially in the The matrix of the cruciate ligaments demonstrates
anterior part where the ligament is in close prox- the following four diff
fferent systems:
imity to the intercondylar notch. Some authors
postulated that the presence of this zone is caused Collagen
by a physiological impingement against the ante-
fferent types of collagen have been identifi fied in
rior part of the intercondylar roof due to the ana-
the ACL and PCL.
tomical orientation of the AM bundle (35). The Th
cytoplasm of the fusiform cells is attached to the Type I collagen is the dominating collagen in liga-
extracellular collagen and seems to play a role in ments and tendons. Its fibers are oriented in a
the typical crimp formation (32,33). In the distal parallel fashion and are responsible for the tensile
part, Duthon et al. (32) found chondroblasts and strength of the ligament.
ovoid fibroblasts, which resembled the cells of Type II collagen can be found at the femoral and tib-
articular cartilage. They have abundant cellular ial insertion sites in the fibrocartilaginous regions
organelles indicating high cellular activity. In the of the ACL. The presence of collagen type II is an
area of the distal ACL insertion, chondrocyte cells indicator of applied pressure or shear as at the
can be seen typically in the zone of fibrocartilage femoral and tibial attachment sites.
and mineralized fibrocartilage that anchors the Type III collagen has been identified
fi in the ACL in
ligament to the bone. the loose connective tissue that separates the type
I collagen bundles. It can be found along the whole
length of both cruciate ligaments with a concen-
tration near the insertion sites (36). This type of
Extracellular components collagen is usually increasingly generated during
the ligamentization process of the remodeling
All cellular components are suspended in a com- replacement graft.
plex three-dimensional matrix of extracellular
Type IV collagen is found in the basal lamina of the
structures. Most of the extracellular volume is
intra- and periligamentous vessels. Signifi ficantly
composed of collagen fi fibrils. Strocchi et al. (29)
more type IV collagen was found in the PCL than
observed two types of fibrils
fi in the ACL: the first
in the ACL. Both cruciate ligaments showed signif-
type was of variable diameter between 35 and 75
icantly lower type IV collagen density in their less
nm and had an irregular outline. They accounted
vascularized mid-portion (36).
for around half of the entire ACL and were secreted
Type VI collagen can be found in both cruciates along
by fibroblasts. It is believed that these large fibrils
the complete length of the ligament with concen-
are designed to resist high tensile stress. Th The sec-
tration in the distal zones and higher expression in
ond type had a uniform diameter around 45 nm
the ACL than the PCL (36). Type VI collagen serves
and comprised around 44% of the entire ACL.
as a gliding component between functional fi fibrillar
This type was secreted by fibro-condroblasts and
units, and its concentration near the attachment
was mainly responsible for maintaining the three-
sites can be explained by the higher strains found
dimensional organization of the ligament. Baek et
in these compared to the mid-substance regions.
al. (30) found that the distribution of these two
types of collagen fibrils varied signifi ficantly along
the length of the ligament and between the ACL Glycosaminoglycans
and the PCL. While the ACL had an increase of These ground substances allow, in combination
average fibril diameter from proximal (66 nm) with proteoglycans, for homogenous distribution
to middle (75 nm) to distal (78 nm), the trend of water throughout the ligaments that accounts
for the PCL was opposite with deceasing average for 60–80% of the total wet-weight of the ACL and
fibril diameter (proximal 90 nm; middle 75 nm; PCL. This leads to modifi
fications of the viscoelastic
16 The Traumatic Knee

properties of the cruciate ligaments and functions tive insertions sites was devoid of vessels as well as
as a protection mechanism against repetitive load- the central part of the middle third of the PCL.
ing. The various branches of the MGA build a synovial
plexus in the epiligament that ensheathes the cru-
Glyco-conjugates ciate ligaments along their entire length. Smaller
These play an important role in intra- and extra- vessels penetrate the ligament transversely to anas-
cellular matrix morphology, cellular adhesion, and tomose with endoligamentous vessels that are lon-
cell migration. In the cruciate ligaments, laminin, gitudinally aligned to the collagen bundles in a par-
entactin, tenascin, and fi fibronectin are found. allel fashion (6). Interestingly, both attachment sites
Duthon et al. reported upregulated concentrations of either cruciate ligament do not contribute to the
in the proximal part of the ACL (32). endoligamentous supply with no crossing of intralig-
amentous vessels to the tibia or femur (20,32,39).
Besides the MGA, small arterioles from the Hoffa ff
Elastic components
fat pad penetrate the ligamentum mucosum (38),
These components are essential for facilitating while infrapatellar branches of the inferior genicular
the large length changes of the ligaments during arteries supply the distal portion of the ACL.
motion (29,36) and therefore can be found pre-
dominantly along the mid-substance of the liga-
ments. Matrix components identified
fi in the ACL
are oxytalan, elaunin, mature elastic fi
fibers, and
elastic membranes. The ACL possesses most of its neural structures in
its subsynovial layer and near the insertion sites
(3). These neural structures originate from the
Vascularity posterior articular branches of the tibial nerve (40)
and penetrate the posterior joint capsule to follow
Both cruciate ligaments receive their vascularity the synovial and periligamentous vessels of the
from the middle genicular artery (MGA) that origi- ACL. The majority of the nerve fibers are associated
nates from the popliteal artery and enters the knee with endoligamentous vasculature, having a vaso-
joint through the dorsal capsule (37,38). From the motor function. Autonomous smaller myelinated
intra-articular part of the MGA, several branches nerve fibers (2–10 m in diameter) and unmyeli-
connect to the various soft tissues of the intrac- nated nerve fibers (1 m in diameter) were identi-
ondylar fossa, such as the cruciate ligaments. Th The fied in the ACL that lied among the fascicles of the
synovial membrane of the ACL becomes vascular- ligament (40). Similar findings were made for the
ized at the junction of the joint capsule distal to the PCL (41). Schultz et al. (42) also found unmyeli-
infrapatellar fat pad, mainly by a large, posteriorly nated axons at the PCL surface, which Solomonow
descending branch of the MGA and small nutrient (43) and Raunest et al. (44) located predominantly
arteries (20,38; Fig. 6). The larger vessels of the at the insertion sites. The receptors of the nerve
MGA descend toward the PCL (37). The Th vascular fibers found in both cruciate ligaments (45) have
density of the ACL decreases from proximal to dis- been identified
fi as:
tal, while the PCL shows a more homogenous and – Ruffi
ffini receptors, which are located on the surface
higher vascular density along its length than the of the entire ligament with concentrations at its
ACL (28). Petersen et al. (37) found three avascular respective attachment sites (46) and are espe-
zones in the PCL: the fibrocartilage of the respec- cially sensitive to stretch;
– Vater-Pacini receptors, which are also located at
the femoral and tibial insertion sites of the cru-
ciate ligaments (41,46,47) and are sensitive to
rapid movements;
– Golgi-like tension receptor, which can be found
throughout the surface, beneath the synovial
membrane, and near the attachment sites of the
cruciate ligaments (41,42,46).
– free-nerve endings, which were recognized as noci-
ceptors as well as local effectors
ff that release neu-
Fig. 6 – Sagittal (A) and coronal (B) views of the vascular anatomy of
ropeptides with vasoactive function, facilitating
the ACL. On the sagittal section, the middle genicular artery leaves the a modulatory effect
ff in normal tissue homeosta-
popliteal artery at a right angle (arrows) crossing the posterior capsule. FP sis (45).
refers to infrapatellar fat pad. (Reproduced with permission and copyright All these neural receptors serve the purpose of
© of Wiley-Liss (38).) proprioception, providing afferent
ff feedback of
The cruciate ligaments: anatomy, biology, and biomechanics 17

ligamentous tension, which affects

ff muscular activ- Both cruciate ligaments exhibit a typical pattern
ity and impacts on overall knee stability. Changes of elongation during loading (Fig. 7). Initially,
in ligament tension initiate the output of muscle only small loads are required to elongate the liga-
spindles through the fusimotor system. Such acti- ment, which is called the “toe region” of their load-
vation of aff
fferent nerve fibers in the proximal part elongation behavior. At these loads, successive
of the ACL has been shown to result into motor recruitment and straightening of ligament fibersfi
activity of the knee flexors
fl and was termed the can be observed. This results into increasing stiff ff-
“ACL reflflex.” Due to the long latency of this refl
flex ness until all ligament fibers are fully load bear-
arc, an automatic protective mechanism cannot be ing and maximum ligament stiffnessff is obtained.
assumed. However, this neural feedback mecha- At this point, a linear relationship exists between
nism seems to play an important role in normal increasing loads and elongation. When the cruci-
knee function and is involved in the updating of ate ligaments are unloaded, a full return to initial
muscle programs (48). A disruption of the ACL and ligament length is observed; therefore, no struc-
the aff
fferent feedback of its mechanoreceptors has tural damage results from loads of the linear load-
been determined to be responsible for the loss of elongation relationship. However, when the yield
accuracy of joint position sense (48). load is reached, non-reversible structural damage
occurs in the ligament, changing the linear rela-
tionship to a non-linear load-elongation behav-
ior, which peaks at maximum (failure) loads,
Biomechanics indicating complete destruction of ligamentous
The ACL and the PCL facilitate an elaborate inter- Another important biomechanical function of
action with the medial and lateral structures, the cruciate ligaments is their viscoelastic behavior
menisci and bony anatomy of the patella, and (10,53). It describes the history- and time-depen-
tibiofemoral joint. This enables the knee joint to dent changes in ligament loading and elongation.
move in six degrees of freedom (three translational When the ligaments are kept at a constant stretch
motions: anteroposterior, mediolateral, proxim- for a continuous time, the load required to main-
odistal; three rotational motions: fl flexion-exten- tain elongation decreases and reaches a steady state
sion, internal-external, abduction-adduction). after a certain time period (53). This phenomenon
The ACL is the primary constraint for anterior is called the stress-relaxation behavior. When liga-
tibial translation (49). It limits internal rotation as ments are exposed to a constant load over a period
a secondary stabilizer, mainly in conjunction with of time, the ligaments lengthen until a steady
the medial collateral ligament and posteromedial state is obtained, which is called creep (53). ThThese
structures of the knee joint (17). properties are facilitated by a complex interaction
The PCL is the primary constraint to posterior of cross-links, collagen fibers,
fi and cellular compo-
tibial translation in flexion (9,17,50). At 90° the nents, such as myofifibroblasts of the ligaments, and
PCL carries 95% of a posterior directed load (49),
which is reduced to 83% or below with increasing
extension (51). Secondary function of the PCL is
to constrain external rotation as well as adduction
and abduction of the knee joint.

Structural and viscoelastic properties

The tensile strength of young human ACL’s has been
determined by Woo et al. to be around 2160 N (52),
while Amis et al. measured forces of 1620 N for
the AL bundle and 258 N for the PM bundle of the
PCL of elder people (75 years) (16). It was shown
that with increasing age the tensile strength of the
ACL was reduced by a factor of 2.5 (52). Based on Fig. 7 – A load-elongation curve can be seen, characteristic for cruciate
ligaments. Initial loads in the toe region result in non-linear increase of
these calculations, Amis et al. (17) estimated the
elongation due to successive fiber recruitment. The linear region deter-
overall PCL strength in young human individuals mines maximum ligament stiffness. At these loads, all ligament fibers are
to be around 4500 N. Similar difffferences have been recruited and no structural damage can be observed. The load-elongation
reported for stiff
ffness of the cruciate ligaments with curve changes to a non-linear relationship after the yield load is reached.
the PCL being substantially stronger (347 N/mm) This is due to increasing structural, non-reversible damage of ligament
(16) than the ACL (242 N/mm) (52). fibers until complete failure takes place at maximal sustained loads.
18 The Traumatic Knee

function to avoid excessive loading of the ligaments The varying function of the ACL and PCL during
during repetitive or continuous exercises. flexion and extension substantially infl fluences the
relative motion of the femur and tibia, respectively.
The coordinated passive action of the cruciates is
Kinematics responsible, in part, for the sliding movement of
the femur during knee flexion beyond 20°. As a
Th fibers of the ACL undergo non-isometric length
The portion of the ACL becomes taut with the continu-
changes during the arc of knee motion, providing ing rollback of the knee, it causes a sliding motion
varying degrees of restraint to anterior tibial trans- between the femur and the tibia around 20° of fl flex-
lation, which is the primary function of the ACL. ion. The PCL, on the other hand, becomes respon-
Takai (54) and Hollis et al. (12) observed that the sible for the posterior sliding movement of the
length of the AM bundle of the ACL increased by condyle during full extension (56).
around 10% (3.3–3.6 mm) during passive flexion fl It has also been shown that muscle activity has a
from 0° to 90°, while the length of the PL bundle considerable impact on knee kinematics, which
decreased between 6% and 32%. This Th underlines substantially changes loads and strains of both
the more dominant function of the AM bundle at cruciate ligaments compared to passive motion of
higher flexion
fl and of the PL bundle near extension the knee joint (10). The
Th strain behavior, i.e., the
in restraining anterior tibial translation. Amis and change of ligament length under a certain load,
Dawkins (11) found that in internal rotation the has been analyzed for the ACL in vitro and in vivo
length increase of ACL fi fibers was more profound (57,58). Beynnon et al. found in in vivo analyses
than during external rotation, highlighting the in human trials that quadriceps activation, extend-
secondary function of the ACL to restrain internal ing the knee joint against a 45-N load, resulted in
rotation. ACL strains of up to 4% near extension (57). He
The primary function of the PCL is to limit poste-
Th also found that loads and strains of the ACL were
rior tibial translation. It was shown that isolated substantially reduced toward higher flexion angles
cutting of the PCL resulted in only small increases with and without quadriceps contraction (59).
in posterior tibial drawer near extension, but in With the knee in 90° of flexion, no changes in
much greater posterior instability toward flexion
fl of ACL strain were observed with quadriceps activa-
the knee joint (9,17). Similar to the ACL, the PCL tion, underlining the dominating function of the
is also a non-isometric structure. The AL bundle ACL near extension (59). Therefore, care should
is the primary restraint to posterior tibial drawer be taken during exercises with quadriceps muscles
from 30° to 120° of flexion with the PM bundle car- activation during the early rehabilitation phase
rying only about 50% of the load of the AL bundle following ACL reconstructions to avoid excessive
during this range of motion (16). Toward fl flexion loading of the graft and its fixation. Hamstrings
greater than 120°, the PM bundle becomes the activation was shown to have a protective effect
ff on
dominant structure in the PCL. Near extension, the ACL. Bach et al. observed that a simultaneous
the PM bundle also carries larger loads than the AL activation of hamstring and quadriceps muscles
bundle. It still does not contribute greatly to resist led to signifi
ficantly decreased strains of the ACL
posterior tibial translation. This might be explained compared to quadriceps activation alone (60).
by its anatomical orientation, which does not allow Other authors discovered signifi ficantly reduced
adequate fiber recruitment following a posterior- anterior tibial translation and internal rotation as
directed force. Therefore, toward full extension, well as substantially reduced forces in the ACL with
other structures than the PCL, especially the PL hamstring contraction, especially at higher fl flexion
structures, are the primary posterior stabilizer of angles (58,61). Therefore,
Th it seems reasonable to
the knee joint (17). It was shown that isolated PCL assume that closed-chain exercises with hamstring
ficiency only resulted in small increases in inter- co-contraction might be benefi ficial during early
nal-external rotation (55). This can be explained by rehabilitation following ACL reconstruction.
the location of the PCL near the rotational center The PCL is protected by quadriceps activity. Covey
of the knee and its small moment arm that can et al. found that a quadriceps force led to signifi- fi
act against internal and external rotation as well cant loosening of PCL fibers
fi at flexion angles less
as abduction and adduction. Therefore, the PCL is than 75° compared to the unloaded passive motion
only a secondary constraint, with posteromedial of the knee joint from 0° to 120° (15). Tibial inter-
and posterolateral structures being the primary nal rotation signifificantly slackened the anterior
stabilizers for rotation and abduction/adduction and central fiber regions near extension and sig-
of the knee joint. This
Th was confi firmed by the obser- nifi
ficantly tightened the central and posterior
vation that only combined injuries of the PCL and fiber regions with progressive flexion. External
PL structures caused significant
fi increases in exter- rotation had an eff ffect similar to internal rota-
nal rotation (50). tion on the anterior and central fiber regions but
The cruciate ligaments: anatomy, biology, and biomechanics 19

caused signifi
ficant slackening of the posterior fiber load of 100 N resulted in PCL in situ forces of 125 N
regions from 0° to 45°. Markolf et al. (58) found a and with additional hamstring activity, an increase
substantial increase in PCL forces with hamstring up to 160 N at flexion angles beyond 80° (58).
activation under a 100-N posterior load between Quadriceps activation did not allow for substantial
30° and 105° and a maximum at 90° of flexion. reduction of PCL in situ forces. Li et al. made simi-
They also found that a posterior load of 100 N did lar observations, with the PCL experiencing in situ
not elicit any force changes in the PCL at exten- forces up to 100 N at 90° of flexion under hamstring
sion, indicating that structures other than the PCL contraction without a posterior directed load. Inter-
take over posterior stabilization of the knee joint. estingly, they found a substantial decrease in PCL
The application of either external or internal rota- loading (35 N) at deep flexion
fl of 150° (65). These
tion resulted in growing PCL forces only at fl
flexion studies imply that active hamstring contraction
angles beyond 60°, which were further increased must be avoided, especially toward mid-flexion
fl at
by hamstring activity. This
Th information must be 90° during the early phase of rehabilitation follow-
considered during rehabilitation after PCL recon- ing PCL reconstruction. Quadriceps co-contraction
struction with quadriceps activity stress-shielding does not provide suffifficient protection of the PCL
and hamstring activity straining the PCL graft. throughout the range of motion regarding the in
situ forces of the PCL.
The knowledge of the anatomy, the biology and
In situu forces biomechanics of the ACL and PCL are the basic
elements for successful treatment of their respec-
Little is known about the in vivo forces that work tive injuries. When performing ACL and PCL
upon the cruciate ligaments during active motion reconstruction, the anatomic landmarks must be
due to the lack of accurate, non-invasive assess- respected and reconstructed. The continuous gains
ment methods. In vivo strain measurements of in knowledge of ACL and PCL biomechanics will
quadrupeds and humans suggest that activities of help to design new techniques that will restore
daily living only cause small loads of about 20% of these properties to facilitate long-term stability
the ACL’s failure capacity (59). and knee function. This will aid to improved graft
In vitro measurements of cadaveric knee joints healing and allow adaptation or even restoration
revealed that the ACL experienced signifi ficantly of the biological properties of the intact ACL. Only
higher in situ forces at or near extension than in then, we will be able to serve our patients in the
flexion (62). Under a 110-N anterior tibial load, in best possible way, so that full return to pre-injury
situ forces of the ACL were 103 N at 15° of flexion, activity and function can be achieved and future
which decreased to 59 N at 90° of flexion, indicating damage of the knee joint can be prevented.
the importance of the ACL near extension. Gabriel
et al. (63) demonstrated that under a 134-N ante-
rior tibial load, the PL bundle carried the highest
in situ forces at extension (67 N), while the AM References
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Chapter 3

A.A. Amis, J.R. Robinson The anatomy and biomechanics

of the medial collateral ligament
and posteromedial corner of the knee

Introduction role, just that there has not yet been serious study
of that. Experience suggests that a very wide yet

he medial and posteromedial aspect of the thin layer of tissue may actually be rather strong.
knee has been studied much less than the The intermediate and deep (capsular) layers of tis-
posterolateral aspect. The underling reason sue contain obvious thickenings or condensations
for that relates to the greater healing potential of of collagenous fibers
fi on the medial and postero-
the medial collateral ligament (MCL), which means medial aspect of the knee. Some of these fibrous
that medial injuries are often treated conserva- tissue bands have been named and their functions
tively, so there has been less pressure to develop examined, including the medial patellofemoral
sophisticated methods to treat these structures ligament.
surgically. A further contributor to this situation This chapter will deal with three principal struc-
is the diff
fference in the mechanical environment, tures: the MCL, which may be split into two lay-
which means that injuries may have diff ffering ers: the deep MCL (dMCL) and the superficial
fi MCL
impacts on function. However, because the clini- (sMCL), plus the posteromedial capsule (PMC).
cian is always alert to the possibility of damage to These are the main units that stabilize the medial
the posterolateral structures, it may be the case aspect of the tibiofemoral joint and will each be
that medial side injuries are not looked for, or that described below. There
Th are other structures that
changes in rotational laxity are misdiagnosed. ThThis make what are assumed to be relatively minor
chapter aims to provide some basic anatomical and contributions to stability of the medial aspect of
biomechanical data that should alert the reader the knee, including the medial patellotibial liga-
to the altered laxity of the knee that results from ment and associated retinacular fibers, but their
damage to the medial and posteromedial struc- contributions to tibiofemoral stability have not
tures and the relative importance of those struc- been studied. This function may be discerned from
tures in the function of the knee. their alignment and attachments and also from
evidence that the retinacula at either side of the
patella contribute to the knee extension moment
(8), thus transmitting tensile forces across the joint
Anatomy line, and therefore compressing and stabilizing
the knee. Because this action derives from muscle
There have been a number of anatomical descrip- actions, the quadriceps acting on the patella, this
tions of the ligamentous and capsular structures may be termed a “dynamic” stabilizing action,
that restrain tibiofemoral motion on the medial rather than the passive actions of ligaments that
and posteromedial aspect of the knee (1–7). A result only from stretching and elastic tension.
review of these shows that many different
ff inter- Dynamic stabilization has other contributors at
pretations of the anatomy have been published. the medial aspect of the knee, such as the medial
That has arisen partly because of the complex- hamstrings muscle tensions. Th These act approxi-
ity of the overlapping arrangement of thin tissue mately parallel to the femur, so they impose an
layers around the medial aspect of the knee. The Th adduction moment across the knee when it is at or
key paper to understanding the anatomy was by near extension and an increasing internal rotation
Warren and Marshall (7), who proposed a system moment as the knee flexes. The semimembranosus
of three layers of tissue (Fig. 1). The
Th more super- is the most interesting of these muscles because it
ficial layer of fascial tissue does not contain obvi- has extensive fibrous bands arising from its distal
ous structural bands linking the femur to the tibia, tendon sheath that diverge in more proximal, ante-
as it wraps over the medial femoral condyle and rior, and lateral directions to attach to thickened
patella. However, although this is a thin layer, that zones in the PMC. It is tempting to suggest roles
does not mean that it has a negligible functional for these bands in stabilizing the knee (9); but they
24 The Traumatic Knee

Patellotemoral Patellotemoral
ligament ligament

medicial Capsule Semimembranoosus
A Superficial
Disseection Point of split natal ligament
kine Dissection layer II


Fig. 1 – The three tissue layers over the medial aspect of the knee according to Warren and Marshall (6). The dissection has proceeded via a longitudinal
incision along the easily palpated anterior edge of the superficial MCL. (Reproduced from Ref. 6 with permission from the J Bone Joint Surg.)

are slack when the knee is extended, because the

tendon is then pulling proximally, and the fibrous
bands buckle in the closing gap between the ten-
don and the posterior condyle, so the tibiofemoral
stabilizing action then derives from the tendon
tension crossing the joint line and not from the
capsular attachments (Fig. 2). TheTh fibrous expan-
sions do tighten when the knee fl flexes, because the
semimembranosus swings with the femur, away
from the axis of the tibia. When the semitendino-
sus pulls posteriorly, it tenses the proximal fi
expansions that link it to the PMC, particularly the
anterior band that attaches below the medial rim
of the tibial plateau, inducing tibial internal rota-
tion (Fig. 3). The
Th reason for this complex structure
is poorly understood.

fi MCL
The superfi
ficial MCL (sMCL) is the most prominent
ligamentous structure of the medial aspect of the
knee. The sMCL is seen as a long and broad band
of tight collagen fibers
fi when the superfi
ficial fascial
layer (layer 1) is removed, so it is a part of War-
ren and Marshall’s (7) intermediate layer 2, which Fig. 2 – At 30° flexion, the semimembranosus tendon tension is acting to
control tibial valgus laxity, as it dissipates distally, at the medial ridge of
is extracapsular (Fig. 1). Th
The sMCL extends from the tibial diaphysis, adjacent to the distal attachment of the long fibers of
the area of the medial femoral epicondyle to the the superficial MCL. Just proximal to the joint line, the posteromedial cap-
anteromedial aspect of the tibia, typically extend- sule (PMC) has slackened and is buckling, revealing the fiber orientation
ing 6–8 cm below the joint line. Flexion-extension that goes distal/posterior from the femoral attachment that is distal to the
of the knee shows that the sMCL remains taut adductor tubercle to the posterior/medial rim of the tibial plateau.
The anatomy and biomechanics of the medial collateral ligament and posteromedial corner of the knee 25

Fig. 4 – In this anterior-posterior view, the forceps has lifted the superficial
MCL away from the femoro-meniscal part of the deep MCL, opening the gap
between them anteriorly, showing their junction posteriorly. The deep MCL
attaches to the rim of the medial meniscus. (Reproduced from Ref. 5 with
permission from the J Bone Joint Surg.)

Fig. 3 – At 80° knee flexion, the posteromedial capsule has slackened fur- 3 mm proximal and 5 mm posterior to the tip of
ther and folded, while the anterior fibers of the superficial MCL are tight. the epicondyle; Hughston and Eilers (2) described
The semimembranosus is now acting as an internal rotator of the tibia, act- this as 10 mm distal and anterior to the adductor
ing via the anterior expansion that attaches on the medial edge of the tibia,
tubercle. As this attachment rotates with knee
below the joint line.
flexion, so the anterior sMCL fibers are stretched
while the more posterior fibers slacken (4; Fig. 3).
across the range of knee motion, leading to the The tibial attachment is approximately 6 cm distal
expectation that it will act to stabilize the knee to the joint line and is approximately 2 cm long; it
against abduction moments at all angles of knee extends distally and slightly posteriorly in a linear
flexion. The long, taut fibers of the sMCL are easily attachment approximately 3 mm wide, close to the
fied, and have a defi
finite and easily palpatable medial ridge of the shaft of the tibia, where it is
anterior edge, anterior to which there is no dense associated with the terminal insertion of the semi-
intermediate tissue layer overlying the joint cap- membranosus and the descending fi fibers of the
sule. A longitudinal incision along this boundary PMC that approach proximally and slightly poste-
allows the anterior fibers of the sMCL to be lifted riorly. Although LaPrade et al. (3) described a pos-
medially away from the deeper structures below; terior proximal sMCL attachment close to the joint
there is an easily penetrated plane between the line, we have interpreted that to be associated with
sMCL and the dMCL and associated capsule below the PMC, while the more anterior sMCL passes
(Figs. 1 and 4). This opening is limited by the fiber over the anterior arm of the semimembranosus
tension, so a distal release is required for more expansion, that attaches just below the joint line.
extensive exposure here. The length of the sMCL attachment gives a range
The femoral attachment of the sMCL is a com-
Th of fiber lengths, so it has been reported to range
pact, approximately 15-mm-diameter ellipse and from 10 to 12 cm overall fiber length.
concentrated into and over the prominence of
the medial femoral epicondyle and into the saddle
proximal/posterior to the epicondyle and so ante- Deep MCL
rior/distal to the adductor tubercle. Because the
deepest fibers run tangential to the bone surface, The deep MCL (dMCL) is a capsular ligament, so
they insert into the distal-facing slope of the epi- it is in layer 3 of Warren and Marshall (7) and is
condyle, while the more superficial
fi fibers pass over attached firmly to the medial rim of the medial
and cover it and insert proximal-posterior to it. meniscus as it passes the joint line (Fig. 5). Th
Thus, although most published descriptions say the dMCL is usually described as consisting of fem-
that the sMCL inserts into the epicondyle (2,10), oro-meniscal and menisco-tibial parts. Th
This distinc-
LaPrade et al. (3) found the center of this area tion is functionally important, because rupture of
26 The Traumatic Knee

has dense fibers arrayed in it that course from the

femoral to the tibial attachments. Among those,
some have been labelled as a “posterior oblique
ligament” (POL) that is a thicker band that passes
in a posterior-distal direction from its attachment
immediately distal/posterior to the adductor tuber-
cle to the rim of the posterior/medial tibial plateau
(Fig. 6). Because the dMCL is capsular, it follows
that the femoral attachment of the PMC is a pos-
terior continuation of that linear attachment that
sweeps posteriorly and then proximally around the
distal and posterior aspect of the adductor tubercle,
before passing laterally, over the top of the medial
femoral condyle. ThThus, the femoral attachment of
the PMC is a long curved line that marks the lim-
Fig. 5 – View of deep aspect of the deep MCL in a disarticulated right knee.
its of the synovial capsule of the medial condyle.
The probe is supporting the anterior edge of the superficial MCL. The deep Similarly, the tibial attachment is linear, around
MCL is tensed, and the meniscus has lifted from the tibial plateau suffi- ffi the posteromedial rim of the plateau, but having
ciently for the menisco-tibial part of the deep MCL to be seen. If the menis- passed over the rim of the plateau, the fibers
fi also
cus lifts much more than this under a valgus moment, it suggests damage continue in a distal-anterior direction to attach
of the menisco-tibial part of the deep MCL. at the medial ridge of the tibial diaphysis adja-
cent to the sMCL. This interpretation of the func-
the more distal part is associated with pathological tional anatomy here diffffers from that described by
mobility of the meniscus, and is identifi
fiable by the LaPrade et al. (3), who did not show a tibial attach-
lifting of the meniscus away from the tibial pla- ment for the PMC or POL; rather, they interpreted
teau when the knee is subjected to an abduction it as attaching to the sheath of semimembranosus.
moment and the interior is viewed arthroscopi- Examination of our own dissections found that
cally. Th
The dMCL is a ribbon of fibers that has linear the PMC was tensed by tibial internal rotation,
attachments to both the femur and tibia, oriented directly between the femoral attachment and the
antero-posteriorly (5). ThThe femoral attachment is rim of the tibial plateau (Fig. 6). Because the PMC
immediately distal to the epicondylar attachment is attached posterior to the femoral axis of flexion,
of the sMCL, while the tibial attachment is to the
medial rim of the tibial plateau and thus close to
the joint line and proximal to the attachment of
the anterior arm of the semimembranosus expan-
sion. The dMCL is overlaid by the sMCL, and their
anterior edges are parallel and close to each other.
The posterior edge of the dMCL is marked by its
blending with the posterior edge of the sMCL
(Fig. 4) so that we may define
fi the structures poste-
rior to this junction as being the PMC. Thus,
Th at this
boundary, layers 2 and 3 blend together to become
a single capsular layer 3. Anteriorly, the joint cap-
sule is relatively thin, so the edge of the dMCL is
easily identified.

Posteromedial capsule
The posteromedial capsule (PMC) has a complex
anatomy, and the literature is not helpful; there are
fferent interpretations. The functional concern is
to identify load-bearing tissue bands that might be
targeted during surgical reconstructions/repairs.
A complex arrangement of distinct and separate Fig. 6 – The posteromedial capsule is tensed by full extension of the knee:
fiber bundles was shown by Hughston and Eilers
fi the bulges of the posterior femoral condyle and the rim of the tibial plateau
(2), but that artist’s impression is not duplicated in are seen. The posterior-distal orientation of the capsular fibers are seen,
reality: the PMC is actually the joint capsule that among which is the band known as the posterior oblique ligament (POL).
The anatomy and biomechanics of the medial collateral ligament and posteromedial corner of the knee 27

it slackens as soon as the knee starts to flex; with ± SD), the dMCL at 194 ± 82 N, and the PMC at
deeper flexion, the slack capsule folds and is car- 425 ± 121 N.
ried anteriorly, beneath the posterior edge of the (b) The sMCL was not signifi ficantly stronger than
sMCL that remains tight when the knee fl flexes the PMC, but both were signifi ficantly stronger
(Fig. 3). Th
The observation of this distinct pattern of than the dMCL.
slackening when the knee flexes,
fl in contrast to the (c) The sMCL had signifi ficantly higher tensile stiff
isometry of the adjacent sMCL, led Fischer et al. ness than the other two structures; the implica-
(11) to speculate that it has a different
ff functional tion of this is that it will take more of the load
role. when an abduction (valgus) moment is imposed
If the dissection of the PMC is continued round to on the knee.
the posterior aspect of the knee, it passes deep to (d) The dMCL failed at signifi ficantly lower elonga-
the medial head of the gastrocnemius and is inti- tion than the other structures (7.1 ± 1.1 mm,
mately attached to it. This
Th part of the capsule is versus 10.2 ± 1.1 mm for sMCL, and 12.0 ±
slack when the knee is flexed
fl and then tensed in 3.0 mm for the PMC).
terminal knee extension by the outward bulge of It is likely that the failure loads will be higher in
the posterior femoral condyle (Fig. 6). younger, more active people than represented by
these cadaveric specimens with a mean age of 77
years. That was suggested by six of eight sMCLs fail-
ing by avulsion of the femoral attachment; a re-test
Biomechanics of the ligament substance was 74% stronger. Bone-
ligament-bone preparations have been used to estab-
Strength of the ligaments lish the eff
ffect of limb immobilization and age on the
ultimate strength of the MCL in animals (16,17).
Several studies have tested the tensile strength of They showed that immobilization caused resorption
the MCL (12–14), but those studies did not sepa- and weakening of the ligament attachment sites.
rate the MCL complex into its three anatomical The lower elongation to failure of the dMCL
structures. Those papers described their speci- explains the clinical finding of dMCL rupture while
mens as having the length of the sMCL fi fibers, so the knee remains stable against abduction (valgus)
it is presumed that the dMCL and the PMC were loading, when the sMCL has not ruptured. Most
discounted in those studies. A more recent study of the specimens failed in the femoro-meniscal
(15) examined the three principal structures using region. The earlier failure of the dMCL relates to
a method of separating them via three tibial bone its shorter fibers, so they are subjected to a higher
blocks: anterior/proximal for the dMCL, posterior/ percent strain elongation, for a given tibiofemoral
proximal for the PMC, and distal for the sMCL. That
Th angulation, than the sMCL and PMC fibers. fi
allowed each ligament to be tested along the line of The PMC had both strength and elongation to fail-
its fibers, with bone-ligament-bone specimens. ure that did not diff ffer signifi
ficantly from those of
The tensile load-versus-extension graphs (Fig. 7)
Th the sMCL. Further, most of the specimens failed in
show several things: their mid-substance, proving that the attachment
(a) All three structures had functionally significant
fi of the PMC to the posteromedial rim of the tibial
strength: the sMCL failed at 534 ± 85 N (mean plateau is structurally significant.

Fig. 7 – Mean tensile force versus

extension graphs for the three
structures: the superficial MCL
(sMCL), the deep MCL (dMCL), and
the posteromedial capsule (PMC).
The crosses show ±1 SD on the
mean failure loads and extensions.
(Reproduced from Ref. 15 with per-
mission from the J Biomech.)
28 The Traumatic Knee

Stabilizing actions Tibial internal rotation was controlled mostly

by the sMCL and PMC; cutting the dMCL had
Valgus-varus rotation no measurable effect.
ff The PMC was dominant at
It has long been known that the MCL is the pri- 0° and 15° knee flexion, where cutting the other
mary restraint to tibial valgus (abduction) rotation structures did not add to the pathological laxity.
and that it does not have a role in varus (18). A The roles swapped over as the knee flexed, so that
more recent study (19) measured the contribu- cutting the sMCL caused the entire increase in
tions of each of the three main structures. When internal rotation laxity at 60° and 90° knee flflex-
the ligaments were intact, valgus laxity in response ion (Fig. 9).
to a 5-Nm bending moment was approximately Tibial external rotation increased after cutting
3°, from 0° to 90° knee flexion. Cutting the sMCL either of the dMCL and sMCL, at all angles of flex-
allowed signifificant increases in valgus laxity, to ion from 0° to 90°. The increase in tibial external
approximately 8°, from 15° to 90° knee flexionfl rotation after cutting the sMCL was significant
(Fig. 8). Further cutting of the dMCL and PMC overall, and was largest, 10°, at 60° and 90° knee
allowed further small but statistically significant
fi flexion. This effffect was less with dMCL cutting,
increases in valgus laxity, which then equalled approximately 5° when the knee was flexed fl 30°
13° ± 3° at 30° flexion. However, when the cut- or more. Kennedy and Fowler (20) found that 45°
ting sequence was reversed, isolated cutting of the tibial external rotation ruptured the dMCL but left
dMCL and PMC did not cause a significant
fi increase the sMCL intact. Slocum and Larson (6) stated that
in valgus laxity. These
Th diff
fferences show that the rupture of the capsular ligament (the dMCL) was
sMCL is the primary restraint to valgus from 0° to the basic lesion allowing abnormal tibial external
90° knee flexion, with the dMCL and PMC acting rotation. Cutting the PMC did not have a signifi- fi
as secondary restraints. The PMC is tight in the cant eff
ffect on tibial external rotation.
extended knee, where it contributed 32% of the
restraint to a 5-Nm valgus moment and the sMCL Tibiofemoral anterior-posterior translation laxity
65%. However, the PMC slackened as soon as the If the tibia is free to rotate during an anterior or
knee started to flex, so the sMCL resisted 96% of posterior (AP) drawer test, then the load is resisted
the load at 30° knee flexion. almost entirely by the cruciate ligaments (21); cut-
ting the three medial structures does not affect
ff the
Tibial internal-external rotation AP laxity signifificantly at any angle of knee flex-
For the intact knee, both tibial internal rotation ion. However, if the tibia is held in a fixed
fi rotated
laxity and external rotation laxity, in response to position during AP drawer testing, the situation
an axial torque of 5 Nm, were smallest with the is diff
fferent. That is because the rotation can both
knee extended (±12°); this increased progressively tighten the peripheral structures and also realign
as the knee flexed, to ±20° rotation at 90° flexion them. For example, tibial external rotation moves
(19). After all three medial structures had been the distal attachment of the sMCL and dMCL ante-
cut, the rotational laxity increased; it then ranged riorly, so they will then be both tight and aligned to
from ±20° in extension to approximately ± 32° at resist anterior drawer. Conversely, tibial internal
30–90° flexion. rotation has a similar effffect on the PMC, so it then

Fig. 8 – Valgus laxity increases in response to 5-Nm moment,

with the knee intact and after sequential cutting of the sMCL,
dMCL, and then PMC. Note that most of the pathological lax-
ity increase occurred after cutting the sMCL while the dMCL
and the PMC were still intact. (Reproduced from Ref. 19 with
permission from the Am J Sports Med.)
The anatomy and biomechanics of the medial collateral ligament and posteromedial corner of the knee 29

Fig. 9 – Tibial internal rotation laxity for the knee intact and
after cutting medial structures. Note how most of the patho-
logical increase in laxity near knee extension resulted from
cutting the PMC, whereas the sMCL was most important in
60° and 90° knee flexion. (Reproduced from Ref. 19 with per-
mission from the Am J Sports Med.)

may resist tibial posterior drawer, particularly near Conclusions

knee extension when it is tighter. ThThese observa-
tions were the basis of the Slocum and Larson tests – The most important structures for passive sta-
for knee stability (6), when the anterior drawer bility of the medial aspect of the knee are the
test was done with the tibia held in neutral and superfi
ficial (sMCL) and deep (dMCL) parts of the
rotated positions, thus demonstrating the actions medial collateral ligament and the PMC.
of the peripheral structures. Robinson et al. (19) – The sMCL attaches over the area of the axis of
found that these maneuvers approximately halved flexion of the femur, so it remains tight across
the tibial anterior drawer test laxity with the tibia the range of knee flexion-extension.
fl Across its
held in fixed external rotation, and posterior laxity width, the anterior fibers are tensed by knee flex-
with fixed internal rotation. During the anterior ion, while the posterior fibers
fi slacken.
drawer test in fixed external rotation, the dMCL – The PMC attaches posterior to the axis of flexion
had resisted 32% of the drawer force and the sMCL of the femur, so it slackens with knee fl flexion.
16%. The greater role of the dMCL arose because – The PMC is tightened by knee extension and tibial
its shorter fibers were realigned more by the tibial internal rotation, when it is an important restraint
external rotation. Similarly, Noyes et al. (22) found to both internal rotation and posterior drawer.
that the MCL (combined sMCL and dMCL) resisted – The sMCL is the principal restraint to valgus
40% and the ACL 52% of the anterior drawer force, (abduction) angulation of the tibiofemoral joint.
with the tibia held in external rotation. The Th role The sMCL takes most of the load because it is
of the dMCL is increased by its attachment to the the stiff
ffest ligamentous structure on the medial
medial meniscus: a rupture of the distal menisco- aspect of the knee.
tibial part mobilizes the meniscus, resulting in – The dMCL is tightened rapidly by tibiofemoral
greater anterior laxity (23). relative motion because its fibers are shorter
The medial structures are important secondary than those of the other ligaments; it has a role
restraints against tibial posterior drawer when the in limiting tibial external rotation and anterior
knee is at or near extension because that is the drawer in external rotation.
most important posture for weight-bearing stabil-
ity. It has been shown (24) that the PCL is only a
secondary restraint to tibial posterior drawer in References
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Chapitre 4

C.J. Griffith, C.A. Wijdicks,

R.F. LaPrade
The lateral collateral ligament
and posterolateral corner

The lateral collateral ligament and recognize in a severely acute injury. Recognition
of the main structures and their relationships
posterolateral corner to each other, in addition to the important bony
landmarks of the posterolateral knee, can simplify
one’s understanding and treatment of injuries to
Anatomy of the posterolateral knee this unique part of the knee.

he anatomy of the posterolateral corner of
the knee has been noted to be very complex Fibular collateral ligament
with 32 individual structures in addition The fibular (lateral) collateral ligament is described
to 3 separate bones that articulate on the lateral as one of the three main structures of the poste-
side of the knee (1). Evolutionary changes of lat- rolateral corner of the knee (Fig. 1A and B) (6).
eral knee structures have disposed it as a complex The fibular collateral ligament (FCL) is typically
structure. Originally, in lower animal species, the 4–5 mm in width and attaches proximally in a
fibula articulated directly with the femur (2–4). fanlike manner on the femur (6). Its proximal
In higher-order mammals, the fibula has migrated attachment on the femur is noted to be slightly
distally and created the complex interactions of the proximal (1.4 mm) and posterior (3.1 mm) to the
posterolateral knee (5). The most complex interac- lateral epicondyle (6). While some of its fi fibers do
tions of the posterolateral knee primarily comprise expand over a portion of the lateral epicondyle,
of the popliteus complex and its attachments to its main attachment site is in a small depression
the fibula and lateral meniscus. It remains recog- just proximal and posterior to the lateral epicon-
nized that the arrangement of these structures is dyle. From its proximal attachment site, it courses
complex and has the potential to be difficult
ffi to extra-articularly under the superfi ficial layer of

Fig. 1 – (A) Cadaveric photograph dis-

playing course of the fibular collateral
ligament from its femoral attachment
posterosuperior relative to the lateral
epicondyle to its attachment on the
lateral fibular head. (B) Illustrative dem-
onstration of both the popliteofibular
ligament from the musculotendinous
junction of the popliteus muscle to the
fibular styloid tip and off the popliteus
tendon. (Reprinted with permission from
Am J Sports Med 31(6): 856, Fig. 1.)
32 The Traumatic Knee

the iliotibial band and the lateral aponeurosis of

the long head of the biceps femoris to attach to
the lateral aspect of the fibular
fi head. It has been
noted to attach to the fibular head in the small
indentation, which is approximately 40% of the
distance from the anterior aspect of the fi fibular
head to the posterior aspect (6). Its attachment
on the fibula is longer in a proximal-distal direc-
tion than its bony attachment on the femur, and
some of its attachment fibers on the fibula have
been noted to blend with the facial fibers of the
peroneus longus muscle (7). A simple method for
fication of the FCL attachment to the fibu-
lar head has been described as a horizontal inci-
sion through the biceps bursa, 1 cm proximal to
the fibular head, where the FCL can be identifi fied Fig. 2 – Superficial band of iliotibial tract anatomy displaying the superfi-
in all but the most severe posterolateral corner cial band of the iliotibial band, which lies superficial to the more posterior
aspect of the vastus lateralis muscle and courses down to attach distally on
injuries (8).
Gerdy’s tubercle.
Iliotibial band
The iliotibial band, also referred to as the iliotibial As mentioned previously, the superfi ficial layer of
tract, is an important landmark over the postero- the iliotibial band serves as an important land-
lateral corner of the knee due to the fact that it is mark to identify other posterolateral corner
rarely injured, and in most surgical approaches to structures intraoperatively because it has been
posterolateral knee structures start with an inci- noted to be only injured in about 3% of postero-
sion directly over the superfi ficial layer of the ili- lateral corner injuries (8). Thus,
Th the iliotibial band
otibial band. The iliotibial band comprises of four can be utilized as an important landmark to iden-
main components over the lateral side of the knee tify all but the most severe posterolateral corner
(9,10). These consist of the superfi ficial layer, the injuries.
iliopatellar band, the deep fibers, and the capsu-
lo-osseous layer (9). TheTh superfi ficial layer of the Mid-third lateral capsular ligament
iliotibial band covers the more posterior aspect The mid-third lateral capsular ligament is a
of the vastus lateralis muscle and courses down thickening of the lateral capsule, which courses
to attach distally on Gerdy’s tubercle (Fig. 2). A from the femur to the tibia and is effectively
portion of the iliotibial band, called the iliopatel- comparable to the deep medial collateral liga-
lar band, courses up to attach to the lateral border ment on the medial side of the knee (10). The
of the patella. Along its more posterior aspects of mid-third lateral capsular ligament femoral
the knee, it blends with the fascial fifibers offff of the attachment site is just anterior to the popliteus
short-headed biceps femoris. tendon attachment on the femur, and its poste-
In the region of the lateral intermuscular septum, rior femoral attachment site is just anterior to
the iliotibial band is attached to the femur by the the lateral gastrocnemius tendon attachment
deep fibers, also called Kaplan’s fibers, and the cap- site (10). It then courses down to attach to the
sulo-osseous layer of the iliotibial band (11). The Th lateral meniscus and then more distally to its
capsulo-osseous layer of the iliotibial band consists attachment site on the tibia. Its tibial attach-
of a fine fascial sling, which attaches to the iliotib- ment site, which is more frequently injured,
ial band in this area, and then courses around the has been known to share a common attachment
anterolateral aspect of the lateral femoral condyle with the anterior arm of the short head of the
to attach distally on the tibia in the same region as biceps femoris and the capsulo-osseous layer of
the meniscotibial attachment site of the mid-third the iliotibial band. Because the two portions, on
lateral capsular ligament (10). ThThe capsulo-osseous each side of the meniscus, have different attach-
layer, also called the retrograde tract fibers by Lob- ments and appear to be of different thicknesses,
benhaufer, has been noted to form an anterolateral they are often referred to as two different struc-
sling over the posterolateral corner of the knee and tures. The portion that attaches to the femur
theorized to contribute to a reduction in the pivot is called the meniscofemoral portion, while the
shift maneuver in the face of an anterior cruciate portion that attaches to the tibia is called the
ligament (ACL) tear. ThisTh portion of the iliotibial meniscotibial portion. As mentioned previously,
band was historically reconstructed in extra-artic- it is the meniscotibial portion that is most com-
ular ACL reconstructions. monly injured. The meniscotibial portion can be
The lateral collateral ligament and posterolateral corner 33

injured with an avulsion of the portion of the Short head of the biceps femoris
tibia, diagnosed as a Segond fracture or with a
The short head of the biceps femoris has five major
soft-tissue avulsion of the structures that attach
components at the knee. Th The first component con-
to the tibia at this location, called a soft-tissue
sists of the main muscle body, which courses off ff
Segond avulsion (12).
the posterolateral aspect of the distal femur and
attaches to the medial aspect of the long head of
Long head of the biceps femoris the biceps femoris main common tendon (10). It
Th long head of the biceps femoris has six diff
The ffer- then has a tendinous attachment with the main
ent anatomic components at the knee. There Th are common tendon, which becomes the direct arm
two tendinous components. Th These are the direct of the short head of the biceps. This Th tendinous
and anterior arms of the long head of the biceps, attachment from the short head of the biceps fem-
which attach to the fibular head. The direct arm oris attaches just lateral to the tip of the fibular
attaches on the lateral aspect of the fibular styloid, styloid (10). Just proximal to its tendinous attach-
while the anterior arm crosses lateral to the fibular ment, there is a very thick and stout capsular arm
head and has a fascial attachment to the aponeu- that courses to the posterolateral joint capsule
rosis that covers the anterior compartment of the and the lateral gastrocnemius tendon. This Th com-
knee. The anterior arm of the long head of the ponent is called the capsular arm. Th The more distal
biceps femoris forms a bursa where it crosses the aspect of the capsular arm attaches to the tip of
distal quarter of the FCL (13). The average length the fibular styloid and attaches proximally to the
of this bursa is 18 mm, and the bursa surrounds region of the fabella on the lateral gastrocnemius
the FCL by approximately 270° (13). An incision tendon. Thus, the more distal aspect of the capsu-
through the biceps bursa is one of the primary lar arm of the short head of the biceps femoris is
incisions utilized to perform repairs or reconstruc- the fabellofi
fibular ligament (6,10). The fabellofi fibu-
tions of the posterolateral corner structures. Th This lar ligament is noted to be very tight in extension
technique is valuable in the scenario of an acute and very loose in flexion.
fl It has been described to
repair of the FCL and a reconstruction procedure have the greatest variability among the posterolat-
(Fig. 3). eral corner structures; however, other studies have
The other components of the long head of the
Th found that its variability is primarily in the overall
biceps femoris are fascial attachments. Proximally, thickness of the tendon and not in its actual pres-
there is a refl
flected arm that courses up to attach to ence (6). Since by defi
finition it is the distal edge of
the posterior border of the iliotibial band. In addi- the capsular arm of the short head of the biceps
tion, there is a lateral aponeurosis that attaches to femoris, we have found it always to be present in
the more posterior and lateral aspect of the FCL. over 300 fresh frozen cadaveric dissections that we
It is believed that, through this attachment, there have performed.
is some dynamic control of the FCL by the biceps Just distal to the capsular arm of the short biceps
femoris complex. Finally, there is a distal aponeu- femoris is a fine aponeurosis that courses from
rosis off
ff the long head of the biceps femoris, which the short-head biceps tendon up to the posterolat-
courses distally and attaches to the lateral gastroc- eral aspect of the FCL. This
Th structure is the short
nemius complex. biceps lateral aponeurosis. And finally, an anterior
arm of the short biceps femoris is present, which
courses medial to the FCL and attaches to the
posterior aspect of the meniscotibial portion of
the mid-third lateral capsular ligament, sharing a
common attachment site with the capsulo-osseous
layer of the iliotibial band (10). We have noted
that the short head of the biceps femoris is com-
monly found to be torn off ff with bony or soft-tissue
Segond avulsions of the tibia both clinically and on
MRI scans (12).

Lateral gastrocnemius tendon

The lateral gastrocnemius tendon is a tendinous
thickening at the far lateral aspect of the lateral
gastrocnemius musculature. It blends impercep-
Fig. 3 – Photograph displaying the biceps bursa, which lies just superficial tively into the meniscofemoral portion of the
to the fibular collateral ligament and serves as the primary incision site for posterolateral capsule at the level of the fabella or
reconstructions of posterolateral corner structures. cartilaginous fabella (10). In our experience, we
34 The Traumatic Knee

have found that there is always a bony or cartilagi-

nous fabella present, and we have performed his-
tological studies on cadavers to verify this. Once
the lateral gastrocnemius tendon attaches to the
fabella, it cannot be separated either surgically or
histologically from the lateral capsule in this area.
The lateral gastrocnemius tendon is rarely injured
in the face of posterolateral corner injuries, and
its femoral attachment site, which is close to the
supracondylar process on the lateral femoral con-
dyle, is a good reference point for treatment of
acute posterolateral corner injuries for repairs or
in the case of acute or chronic posterolateral cor-
ner reconstructions (6).

Popliteus complex
The popliteus complex, which is a very important
posterolateral rotatory stabilizer to the knee, has
both a static and a dynamic function. TheTh main ten-
dinous attachment of the popliteus muscle is at the
top fifth of the popliteal sulcus. At this location,
the center of the popliteus tendon attachment is
18.5 mm anterior to the center of the FCL attach-
ment on the femur (6). As one courses distally, the
popliteus has three popliteomeniscal fascicles that Fig. 4 – Photograph displaying the courses of both the anterior and poste-
attach the lateral meniscus to the popliteus ten- rior (pointer) attachment sites of the popliteofibular ligament (PFL) from
don (6,10,14). These occur in the popliteal hiatus. the musculotendinous junction of the popliteus muscle to the fibular sty-
These include the anteroinferior, posterosuperior, loid tip and off the popliteus tendon (posterior view, right knee). FCL, fibu-
and posteroinferior popliteomeniscal fascicles. lar collateral ligament; PLT, popliteus tendon. (Reprinted with permission
The anteroinferior popliteomeniscal fascicle is the from Am J Sports Med 31(6): 858, Fig. 4.)
strongest and provides the most stability to lateral
meniscal motion (15). As one courses further dis- ally just lateral to the posterior cruciate ligament
tal, at the level of the popliteus musculotendinous (PCL), and its lateral border is at the edge of the
junction, the popliteofi fibular ligament courses from popliteal hiatus. This structure is thought to pro-
the popliteus tendon down to the posteromedial vide some stability to the posterior horn of the
aspect of the fibular styloid (Figs. 1B and 4). There lateral meniscus and possibly some function in
are two divisions to the popliteofi fibular ligament. preventing hyperextension. However, its specific fi
These include the anterior and posterior divisions. function has not been identifi fied through biome-
The posterior division is larger and is believed to be chanical testing to this point in time.
stronger. Anatomically, the more proximal aspect of
the popliteofifibular ligament blends with the more
distal aspect of the popliteomeniscal fascicles.
In addition to these attachment sites, there is also Biology of posterolateral knee injuries
a stout attachment that courses from the more
proximal aspect of the popliteus muscle up to the The bony architecture of the posterolateral corner of
posterior aspect of the posterior horn of the lat- the knee difffferentiates it signifi
ficantly from that of
eral meniscus. This structure is called the popliteal the medial side of the knee. The two convex oppos-
aponeurosis. In some of the older literature, this ing surfaces of the lateral femoral condyle and lateral
structure was referred to as part of the arcuate tibial plateau have an inherent bony incongruity that
ligament (16). requires the native ligaments to be intact to make it
stable. This bony architecture is diff fferent than the
medial side of the knee, which has a convex shape of
Coronary ligament to the lateral meniscus the medial femoral condyle and the concave surface
The coronary ligament to the lateral meniscus is of the medial tibial plateau to provide bony stabil-
the meniscotibial portion of the posterior capsule, ity. Thus, this bony architecture incongruity, com-
which extends laterally from the popliteomenis- bined with the dependence upon the attachments
cal fascicles back medially to the root attachment to the fibular head and styloid of several structures
of the lateral meniscus (10). It originates medi- to provide bony stability, indicates that posterolat-
The lateral collateral ligament and posterolateral corner 35

eral knee injuries are at a much higher risk of not

healing when treated non-operatively, compared
to medial-sided knee injuries. A study by Kannus
reported that patients with grade 3 posterolateral
corner injuries do not heal and that these patients
often go on to develop signifi ficant instability and
osteoarthritis over time (17).
The clinical observation in humans that the poste-
rolateral structures do not heal when injured has
also been proven in the animal model. Th There have
been three animal model studies that have had
the anatomy of the posterolateral corner studied
in detail and then went on to in vitro or in vivo
cutting studies. The
Th rabbit model was first studied
(18–20). The rabbit anatomy was found to be simi-
lar to the human knee for the popliteus tendon and
the FCL, but no distinct popliteofi fibular ligament
was observed. The bony architecture of the rabbit
was found to be similar to the human except that
the tibia and the fibula were fused. In both 3- and
6-month cutting studies, it was found that there
was gross instability produced in the rabbit knees Fig. 5 – Photograph demonstrating preoperative examination under anes-
after posterolateral corner sectioning and that the thesia during surgical procedure to section posterolateral knee structures
posterolateral corner structures did not heal over in a goat model.
time. While there was a trend noted to the devel-
opment of medial compartment osteoarthritis,
the number of rabbits utilized in the study was not of the FCL, popliteus tendon, and popliteofibular
fficient to find signifi
ficant amounts of osteoar- ligament were similar to the human knee. Biome-
thritis. chanical testing on a canine knee model also found
The second posterolateral injury model that was that there was a signifificant amount of instability
studied utilized the goat (Fig. 5). The goat model produced by sectioning the FCL, popliteus tendon,
was chosen because of its larger size and its ability and popliteofifibular ligament. While the canine
to potentially perform both cruciate ligament and knee is currently being investigated as to a poten-
posterolateral corner reconstructions on it. How- tial model to determine the outcomes of untreated
ever, the bony architecture of the goat knee is sig- posterolateral corner injuries and to determine if
fi diff
fferent from that of the human. There possible interventional studies can prevent the
is no distinct fibula in the goat, and the fibular head secondary instability and development of osteoar-
is fused to the lateral tibial plateau and positioned thritis, these in vivo studies are still ongoing at
more proximally than in humans. After in vivo this point in time.
studies were completed, it was recognized that this
fused fibular head creates a more concave shape of
the lateral tibial plateau and provides more bony Biomechanics of the fibular (lateral) collateral ligament
congruity in the goat knee than either in the human and posterolateral structures
or in the rabbit knee. While both 3- and 6-month
studies found that there were significant
fi amounts Almost all of the biomechanical studies on the
of posterolateral instability on biomechanical test- posterolateral knee have been evaluated largely
ing, these were not felt to be clinically significant,
fi through cadaveric sequential sectioning studies.
and there was no trend toward the development of In these studies, motion changes are assessed
osteoarthritis in the goat knee model. and utilized to determine the contribution of the
Finally, a canine model was studied in which both sectioned structure for overall knee stability for
anatomic and biomechanical evaluations were per- certain applied loads. It is unfortunate that many
formed on the posterolateral corner of the knee of of the biomechanical studies performed between
cadaveric specimens (21). In the study by Griffith ffi diff
fferent study groups across the world are diffiffi-
et al., they found a similar bony architecture in the cult to compare to each other because of the dif-
canine knee to the human knee. The fibula was not ferences in nomenclature and the fact that many
fused to the tibia, and there were two opposing of the cutting studies grouped and sectioned sev-
convex surfaces present on the lateral side of the eral posterolateral structures together. The
Th follow-
knee. In addition, the attachment sites and courses ing sections examine the different
ff applied forces
36 The Traumatic Knee

and which structures have been determined to be signifi

ficant increase in anterior tibial translation
the primary and secondary stabilizers to resisting (23,25,27). However, it has been demonstrated
abnormal increases in these joint motions. that when the ACL has been sectioned, further
sectioning of the posterolateral corner structures
Role of the posterolateral structures in preventing varus results in a significant
fi increase in anterior tibial
and valgus rotation translation (27,29,30).
All published biomechanical studies have dem- Thus, while it has been found that the posterolat-
onstrated that the fibular (lateral) collateral liga- eral corner structures have very little primary role
ment is the primary restraint to varus motion in in preventing anterior tibial translation, they do
all degrees of knee flexion (22–26). In fact, while have an important secondary role to preventing
isolated sectioning of the FCL has been noted to anterior tibial translation in the face of a concur-
cause a significant
fi increase in varus rotation at rent ACL tear. This observation is clinically very
any knee flexion angle, varus rotation has not important because a patient who demonstrates
been found to be increased with any other poste- a 3+ or 4+ Lachman test has a high probability
rolateral structure sectioning as long as the FCL is of having a concurrent loss of an important sec-
intact (23,24). ondary restraint. In a large number of cases, this
Many of the different
ff structures have been found defi
ficiency would be the posterolateral corner
to be important in providing secondary varus structures. Thus, any patient who is found to have
stability in FCL-deficient
fi knees. Nielson and Hel- a signifi
ficant increase in anterior tibial translation
mig reported that the popliteus tendon had an on their Lachman’s test clinically should be evalu-
important secondary stabilizing role to preventing ated to be sure that there is no concurrent postero-
abnormal varus rotation of the knee after fibular lateral corner structure injury.
collateral sectioning (27). Gollehon et al. found
that sectioning the popliteus tendon and postero- Role of the posterolateral corner structures in preventing
lateral capsular structures signifi ficantly increased posterior translation of the tibia
varus opening, while Grood et al. found that sec-
tioning the popliteus tendon and posterolateral The posterolateral knee structures have been noted
capsule, along with any structures attached to the to play a statistically significant
fi but minor clini-
fibular head, resulted in further signifi ficant varus cally important primary role in restricting poste-
opening of the knee compared to isolated fibularfi rior tibial translation. Studies have demonstrated
collateral sectioning alone (23,25). that isolated sectioning of the posterolateral struc-
tures can result in a slight, but significant,
fi increase
In addition to the posterolateral structures, both
in posterior tibial translation at all angles of knee
cruciate ligaments have been noted to resist varus
flexion (23,25,30). However, in the majority of
rotation when the FCL and other posterolateral
patients with defi ficiencies of the posterolateral cor-
structures have been sectioned. Gollehon et al.
ner structures, the largest increase in posterior tib-
reported that after the FCL and posterolateral
ial translation was close to extension. In addition
structures were sectioned, sectioning of the PCL
to this minor primary role of the posterolateral cor-
resulted in a large increase of varus rotation, which
ner structures in restricting increases in posterior
was signifificantly increased to isolated cutting of
tibial translation, these structures have also been
the FCL (25). Grood et al. also found that after cut-
found to have a very important secondary role in
ting the FCL, popliteus tendon, and posterolateral
providing posterior stability to the knee when the
structures, there was a significant
fi further increase
PCL is sectioned. Both isolated popliteus tendon
in varus opening of the knee when the PCL was
sectioning and combined popliteus tendon and
sectioned (23). Nielsen and Wroble both reported
posterolateral corner structure sectioning in PCL-
that sectioning the ACL after the posterolateral
defificient knees resulted in a rather dramatic and
corner structures and FCL have been sectioned
signifificant posterior tibial translation (23,25,27).
resulted in a signifificant increase in varus opening
of the knee (27,28). To summarize, posterolateral corner structures
No studies to date have found any role of poste- have both a primary and a secondary role to pro-
rolateral structures in preventing increased valgus viding posterior stability to the knee. The primary
rotation after posterolateral corner structure sec- role in preventing abnormal posterior tibial trans-
tioning (25,27,28). lation is minor, and most of this function occurs
near extension. However, there is also a rather sig-
ficant secondary role to preventing posterior tib-
Role of the posterolateral structures in preventing anterior ial translation in PCL-defi ficient knees. The clinical
tibial translation importance of this observation is that in patients
It has been demonstrated that isolated section- with PCL tears, a 3+ posterior drawer test or
ing of the posterolateral structures results in no increases of posterior tibial translation more then
The lateral collateral ligament and posterolateral corner 37

12 mm on bilateral PCL stress x-rays would have a

high chance of having a concurrent posterolateral
corner injury in addition to the PCL tear.

Role of the posterolateral corner structures in preventing

internal rotation at the knee
Several studies have demonstrated that isolated or
combined sectioning of the FCL and other poste-
rolateral corner structures results in a significant
increase of internal rotation at the knee (23,24,31).
In addition, Wroble demonstrated that in the ACL-
fi knee, sectioning the posterolateral cor-
ner structures resulted in a significant
fi increase in
internal tibial rotation (28). Most of the significant
increase in internal tibial rotation was found near Fig. 6 – Photograph demonstration positive dial test of the left knee during
extension. preoperative examination under anesthesia.
In summarizing the role of the posterolateral cor-
ner structures in preventing internal rotation of similar to the amount of external rotation seen at
the tibia on the femur, the posterolateral corner 30° of knee flexion with isolated posterolateral cor-
structures do have a small role in preventing pri- ner structure sectioning.
mary internal rotation. In addition, they have been The clinical implication of this observation is that
found to be important as a secondary restraint to for isolated posterolateral corner injuries, there
internal rotation in the ACL-defi ficient knee, espe- should be a decrease in the amount of external
cially with a knee that is close to full extension. rotation of the tibia on the femur when the dial
However, the clinical usefulness of determining test is performed at 90° compared to 30° of knee
increased internal rotation has not been deter- flexion (Fig. 6). If there is a PCL or ACL injury con-
mined to date because of the large variability current with this posterolateral corner injury, the
and the amount of internal rotation that occurs amount of external rotation found at 90° of knee
between different
ff knees. flexion should be similar to the amount of external
rotation seen at 30° of knee flexion. Thus, if the
Role of the posterolateral corner structures in preventing dial test is found to be signifi ficantly increased at
external rotation at the knee both 30° and 90° of knee flexion, there is a high
likelihood of a combined cruciate ligament injury.
It has been well demonstrated that the posterolat-
eral corner structures have a very important role
to preventing external rotation of the knee. ThereTh Role of the popliteomeniscal fascicles to lateral meniscal
have been many studies that have demonstrated stability
that the greatest amount of external rotation is at Simonian et al. found that sectioning the poplit-
30° of knee flexion and averages between 13° and eomeniscal fascicles resulted in a significant
fi increase
17° of external rotation (23–25). In addition, in of anterior motion of the lateral meniscus when
all of these studies, it was found that as the knee loaded (15). They also found that the anteroinferior
was flexed further, the amount of external rota- popliteomeniscal fascicle was larger and provided a
tion decreased only when the posterolateral corner greater amount of stability to the lateral meniscus
structures were sectioned. ThThe amount of increased than the thinner posterosuperior popliteomeniscal
external rotation of the knee with isolated poste- fascicle. They theorized that with loads seen during
rolateral corner structure sectioning is between 5° normal daily activities, it might be expected that
and 7° at 90° of knee flexion (23–25). The clinical mechanical symptoms would develop in patients
ficance of these findings is that the dial test at when the popliteomeniscal fascicles were torn
both 30° and 90° of knee flexion is based upon the because of the increased meniscal motion.
results of these biomechanical studies (23–25). In
addition to isolated posterolateral corner structure
sectioning, it has been found that sectioning both
ffects of a posterolateral corner injury on joint contact
the ACL and the PCL has been found to result in forces in the knee
increased external rotation of the knee at 90° of Skyhar et al. reported on alterations in joint contact
knee flexion when the posterolateral corner struc- pressure in the knee for PCL- and posterolateral
tures are sectioned first (23,25,28). In fact, the corner structures-defificient knees (32). The study
amount of external rotation seen at 90° of knee found that there was a significant
fi increase in joint
flexion with either an ACL or a PCL injury will be
fl contact pressures in both the patellofemoral joint
38 The Traumatic Knee

and the medial compartment of the tibiofemo- One study found that with application of a varus
ral joint when the PCL is sectioned. The highest load to the knee, there was a fairly constant load
increase in joint contact pressures were seen with response on the FCL at 0°, 30°, and 60° with a
additional combined sectioning of the posterolat- decrease in the overall load response at 90° of knee
eral structures. From the study, the authors con- flexion (36). With the FCL intact, there was very
cluded that patients with combined PCLs and little force on the popliteus tendon and popliteo-
posterolateral knee injuries should be counseled fibular ligament. With external rotation loads, the
about the increased risk of osteoarthritis of these highest amount of force on the FCL was at 0° of
compartments if these injuries are not treated sur- knee flexion. The popliteus tendon and the popli-
gically. teofi
fibular ligament exhibited similar loading pat-
terns with external rotation moments. The Th mean
Biomechanical failure properties of the posterolateral load response on both the popliteus tendon and
structures of the knee the popliteofi fibular ligament was highest at 60°
in knee flexion. Overall, there was a signifificantly
The individual failure characteristics of the FCL, decreased load on the popliteus tendon and the
popliteofifibular ligament, and popliteus tendon popliteofifibular ligament at 0° compared to the
have been more recently defined.
fi Previous studies other degrees of knee flexion.
fl Overall, there was
found that the mean ultimate tensile strength of found to be a reciprocal relationship of load shar-
the FCL was 295 N, the popliteofi fibular ligament ing in external rotation between the FCL and the
was 298 N, and the popliteus tendon was 700 N popliteus complex depending upon the knee flex- fl
(1). Another study by Sugita and Amis found that ion angle that was tested. Overall, the force on
the individual tensile strength of the FCL was 309 the FCL with external rotation loads was higher
N and that of the popliteofi fibular ligament was 180 than the popliteus complex loads at lower flexion
N (33). Maynard et al. tested the combined tensile angles, with the popliteus complex having higher
strength of the lateral (fi
fibular) collateral ligament, load sharing against external rotation at 60° and
popliteofifibular ligament, and popliteus tendon 90° of knee flexion.
and simultaneously stretched all three structures
along the axis of the FCL (34). Their
Th mean tensile These direct force measurements have determined
strengths under these testing conditions were 750 that the FCL is an important load-sharing structure
N for the FCL and 425 N for the popliteofibular fi against external rotation force near extension. In
ligament. Thus,
Th it is clear that the failure proper- fact, it was more highly loaded than the popliteus
ties of these three structures can resist fairly large complex, which would imply that the FCL has an
loads prior to failure, but they are not as strong important role in preventing external rotation in
as the native ACL or PCL. In analyzing the failure early knee flexion that was not recognized in previ-
properties for these three important posterolateral ous posterolateral knee cutting studies.
knee structures, it has been recommended that the
minimum possible graft replacements for these The eff
ffects of deficient posterolateral corner structures
structures consist of a semitendinosus tendon on cruciate ligament reconstruction grafts
(maximum failure load, 1216 N), a central quad- There have been several studies that demonstrated
riceps tendon graft (maximum failure load, 1075 that if the posterolateral corner structures were
N), or a portion of an Achilles tendon allograft not present, there was a significant
fi increase in
(maximum failure load, 3055 N) (1,31,35). Due to force on both ACL and PCL reconstruction grafts,
the lower overall ultimate tensile strengths of the which could lead to their failure. Based on these
gracilis tendon and a tubularized superfi ficial layer studies, it has been recommended to concurrently
of the iliotibial band, it is not recommended that reconstruct the posterolateral corner structures at
these grafts be utilized to reconstruct these poste- the same time as cruciate ligament reconstructions
rolateral knee structures. to minimize the chance of the graft stretching out
and failing over time.
Force measurements to applied loads on posterolateral Early on in our evaluation of posterolateral cor-
corner structures ner knee injuries, we found a high rate of ACL
In additional to information gained from biome- reconstruction graft failures that were referred
chanical cutting studies, the primary and second- to us for treatment that had concurrent postero-
ary stabilizing functions of the posterolateral cor- lateral corner injuries which had not been treated
ner structures have also been studied directly by which lead to the ACL graft failure. This
Th observa-
measuring the force of these structures to applied tion prompted biomechanical testing of the force
loads. This information helps in analyzing the total seen on an ACL graft in the face of deficient
fi poste-
ffect and importance of these individual struc- rolateral corner structures. Tests were performed
tures on knee stability during functional loads. on cadaveric knees with the posterolateral corner
The lateral collateral ligament and posterolateral corner 39

structures first intact and then following section- et al. reported that the failure strength of a patellar
ing of the FCL, popliteofifibular ligament, and popli- tendon ACL graft was 416 N immediately follow-
teus tendon (Fig. 7). Overall, we found a significant
fi ing reconstruction, one can see that this adduction
increase in graft force after FCL sectioning during moment force on an ACL reconstruction graft in
varus loading at both 0° and 30° of knee fl flexion, the face of concurrent posterolateral corner inju-
as well as for coupled loading of varus and inter- ries can be signifi
ficant (38). Based on this informa-
nal rotation moments at 0° and 30° of knee flexion tion, we recommended that strong consideration
(Fig. 8). The increase in graft force that was found be given to either repairing or reconstructing pos-
remained signifificant with additional sectioning of terolateral corner injuries, especially in those knees
the popliteofi
fibular ligament and the popliteus ten- with evidence of injury to the FCL and concurrent
don. In comparing the forces seen on the graft, for varus instability, at the time of ACL reconstruc-
a patient with a typical body weight and height, and tion. This combined procedure would signifi ficantly
a 6% adduction moment to the knee, we calculated reduce the risk of ACL graft failure.
that there could potentially be 444 N of force on A subsequent study was performed to assess the
the ACL reconstruction graft (37). Since Rowden risk of absent posterolateral corner structures on
a PCL graft (Fig. 9) (39). In this study, section-
ing of the popliteus tendon, popliteofi fibular liga-
ment, and FCL signifi ficantly increased the force
on a PCL graft over the intact state. The largest
increases in force on the PCL graft occurred both
with a varus moment and with a coupled posterior
drawer force and external rotation torque. These Th
loading states independently caused a significant fi
increase in graft forces at 30°, 60°, and 90° of knee
flexion when a posterolateral knee injury was pres-
ent (Fig. 10). Thus, this study verifified the clinical
observation that untreated posterolateral knee
injuries contributed to PCL graft failure by signifi- fi
cantly increasing forces on the PCL graft. Th Thus, we
recommended the repair or reconstruction of the
posterolateral corner structures at the same time
as PCL reconstruction in combined posterolateral
Fig. 7 – ACL graft force-measuring
testing apparatus for loading and corner and PCL injuries with evidence of either
force measurement on the ACL increased varus or coupled posterior drawer and
graft during testing. (Reprinted external rotation instability. Th This simultaneous
with permission from Am J Sports repair or reconstruction will decrease the chance
Med 27(4): 470, Fig. 1.) of PCL graft failure after the reconstruction.

Fig. 8 – Graph depicting the absolute tensile forces on ACL grafts to applied loads with posterolateral corner structures in the intact, transected, and recon-
structed states. (Reprinted with permission from Am J Sports Med 27(4): 472, Fig. 3.)
40 The Traumatic Knee

force caused the tibia to rotate externally (Fig. 11).

Thus, it was found that if the ACL graft was tight-
ened before the posterolateral corner structures
were repaired, there was a significant
fi increase of
external rotation of the tibia on the femur. Thus,
we recommended that injured posterolateral cor-
ner structures be repaired or reconstructed prior
to fixation of ACL grafts to minimize the risk of
developing an external rotation deformity of the

Biomechanical analysis of posterolateral corner

reconstruction procedures
There is a paucity of studies in the literature that
have analyzed whether posterolateral corner recon-
Fig. 9 – Tensioning apparatus on the struction procedures restore normal joint motion.
proximal posterior tibia to measure More recently, two studies have analyzed anatomic
force on the PCL graft. (Reprinted reconstructions of the fibular (lateral) collateral
with permission from Am J Sports ligament as well as the FCL, popliteus tendon, and
Med 30(2): 234, Fig. 1.) popliteofi
fibular ligament in an attempt to restore
stability to the knee with fibular (lateral) collateral
Influence of the integrity of the posterolateral structures ligament injuries or complete grade 3 posterolat-
eral corner injuries.
on tibiofemoral orientation when an anterior cruciate
A study by Coobs et al. examined an anatomic
ligament graft is Tensioned reconstruction of the FCL using an autogenous
A specifi
fic study was initiated to attempt to answer semitendinosus graft (Fig. 12A and B) (41). In
the question on whether either the posterolateral this reconstructive procedure, 7-mm tunnels were
corner structures or the ACL graft should be tight- drilled at the attachment site of the FCL on the
ened first at the time of a repair or reconstruc- femur and a 6-mm tunnel was drilled from lateral
tive procedure (40). In this study, an ACL graft to posteromedial through the fibularfi head. The
was tensioned at increasing graft forces both with tunnel entered the fibula at the anatomic attach-
and without the posterolateral corner structures ment site of the FCL. Comparisons were made
being intact. It was found that in a knee deficient
fi to varus rotation, external rotation, and internal
of posterolateral corner structures, increasing the rotation at 0°, 15°, 30°, 60°, and 90° of knee flexion.
traction force on an ACL graft while tensioning on This study validated that an anatomic FCL recon-
the tibia with greater than a 60-N distal traction struction using an autogenous semitendinosus

Fig. 10 – Graph depicting the absolute tensile forces on PCL grafts to applied loads with posterolateral corner structures in the intact, transected, and
reconstructed states. (Reprinted with permission from Am J Sports Med 30(2): 236, Fig. 3.)
The lateral collateral ligament and posterolateral corner 41

Fig. 11 – Graph depicting the change in relative position of the tibia with
respect to the femur resulting from sectioning all of the posterolateral cor-
ner structures.
Fig. 13 – Illustration depicting the anatomic reconstruction of the fibular
collateral ligament, popliteus tendon, and popliteofibular ligament. FCL,
fibular collateral ligament; PLT, popliteus tendon; PFL, popliteofibular liga-
ment. (A) Posterior view, right knee. (B) Lateral view, right knee. (Reprinted
with permission from Am J Sports Med 32(6): 1410, Fig. 3.)

could not adequately restore the normal motion

of the knee with such a large difference
ff in posi-
tion between these two attachment sites. Thus,
we worked concurrently with our colleagues at the
University of Oslo on a surgical approach and, after
several diff
fferent techniques were trialed, arrived at
our current technique, as we felt it was the most
reproducible. It was then tested biomechanically
to determine if it could restore static stability to
A B varus translation, as well as internal and external
Fig. 12 – Illustration depicting the anatomic reconstruction of an isolated rotation. This study found that an anatomic pos-
FCL injury using a semitendinosus graft. The intact popliteus tendon and terolateral corner reconstruction technique that
popliteofibular ligament are also shown. (A) Posterior view, right knee. (B) reconstructs the FCL, popliteus tendon, and popli-
Lateral view, right knee. FCL graft, fibular collateral ligament reconstruc- teofi
fibular ligament restored varus and external
tion with an autogenous semitendinosus graft; PLT, popliteus tendon; PFL, rotation stability in knees with grade 3 posterolat-
popliteofibular ligament. (Reprinted with permission from Am J Sports Med eral corner injuries.
35(9): 1523, Fig. 2.)

graft restored near-normal stability to knees with References

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42 The Traumatic Knee

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Chapter 5

H. Tohyama, K. Yasuda Basic science of ligament healing

Structure of ligaments with periosteal collagen fibers,

fi which in turn are
anchored to the adjacent bone without a fibrocar-

igaments function as short bands of fibrous
fi tilage layer. Indirect insertions contain Sharpey’s
connective tissue that connect bone or sup- fibers, which are collagen fibers that are continu-
porting soft tissue structures. The organiza- ous from ligament to bone and have an important
tion of the ligament is hierarchical. Ligaments are role in securing the ligament to bone. An example
composed of bundles of type I collagen fi fiber, which is the insertion of the medial collateral ligament
make approximately 70% of the dry weight of the (MCL) into the tibia.
tissue (1). Small amounts of elastin are present, A complex blood supply with a fairly uniform
with rows of fibroblasts within parallel bundles of microvascular pattern runs throughout the liga-
extracellular matrix. In the hierarchical structure ment substance, originating from the insertion
of the ligament, the collagen matrix comprises a sites and passing through the ligament in a longi-
series of fibrils, which are then grouped into fibers tudinal fashion. The vessels are small but appear
forming a subfascicular unit (Fig. 1) (2). ThThe sub- critical in nutrition of the central portion of the
fascicular units are surrounded by a thin layer of ligament (4). Although diff ffusion from the syn-
connective tissue. Multiple subfascicular units are ovium or extracellular space is also important for
bound together to form a fasciculus that can range the nutrition of the ligament, a vascular supply
from microns to millimeters in diameter.
At ligament insertion into bone, the ligament
material changes from rigid to more flexible. fl
Insertions are classifified as direct or indirect (3).
Direct insertions are typically associated with
long ligaments inserting into small areas of bone,
while indirect insertions are usually short liga-
ments inserting into a large area. Direct insertion
shows four distinct zones: ligament, unmineral-
ized fibrocartilage, mineralized fibrocartilage, and
bone (Fig. 2). The femoral origin of the anterior
cruciate ligament (ACL) is a direct insertion. Indi-
rect insertions contain collagen fi fibers that blend

Fig. 1 – A schematic diagram of the structural hierarchy of ligament. There

are six distinctive structural levels in a ligament or a tendon. The first level is
the collagen molecule described below; the sixth level is the tendon itself. Fig. 2 – Direct insertion of the ligament shows four distinct zones: liga-
In between, in ascending order are the microfibrils, the subfibrils, the fibrils, ment (I), unmineralized fibrocartilage (II), mineralized fibrocartilage (III),
and the fascicles. (From Ref. 2.) and bone (IV).
44 The Traumatic Knee

is necessary for adequate nutrition of the central General wound healing

portion of the ligament (5). Th
Therefore, disruption
of the blood supply may adversely affect
ff viabil- Healing of an injury to a connective tissue struc-
ity of intraligamentous cells and the remodeling ture including a ligament requires complex inter-
of the extracellular matrix, resulting in possible actions between cells, extracellular matrix, growth
increased risk for rupture of the ligament. Various factors, and mediators of the infl flammatory
nerve endings have been found in ligament tissue. response (10–12). An optimal sequence and timing
Histolochemical studies have shown nerve endings of the stages of soft tissue repair are necessary for
involved in proprioception and nociception in knee successful healing. Th
The alteration of the sequence
ligaments (6,7). or the timing after an injury of connective tissue
structure may induce scar formation and dysfunc-
tion of the healing tissue rather than recovery of
normal structure-function relationship. Wound
Mechanical properties of ligaments healing can be basically divided into infl
proliferative, and maturation phases as described
Tensile testing of ligaments is widely used to below, although these phases can be modifi fied by
evaluate mechanical properties of ligaments the size and location of the injury, vascular supply,
(8,9). The force-elongation curve of the liga- and local mechanical environments (13).
ment tissue follows a pattern consistent with The inflflammatory phase of wound healing begins
collagenous tissues (Fig. 3). The ligament ini- immediately after injury with influx
fl of blood into
tially has a non-linear structural response to an the wound site and subsequent formation of a
applied tensile force. This “toe” region has been fibrin clot. The binding fibrin and fibronectin in
attributed to straightening of the crimp pattern the clot initially stabilize the injury site in spite
and to non-uniform recruitment of individual of its low mechanical strength. Platelets, neutro-
nonparallel fiber in the ligament tissue. If we phils, and macrophages migrate into the injury
apply a tensile force to the ligament, a small site, and these cells release chemotactic factors for
force induces elongation of the ligament tissue fibroblasts and proteolytic enzymes such as matrix
as some crimps are straightened. Additional metalloproteinases (MMPs).
applied load elongates the fibril of the ligament During the proliferative phase of the wound heal-
tissue. As the ligament tissue has varying crimp ing, endothelial cells and fibroblasts, including
and fibril orientation in contrast to the tendon myofifibroblasts, accumulate at the injury site. Typi-
tissue, ligaments may resist stretch at different fied by vascular endothelial growth factor (VEGF),
levels of elongation. With increase in the elonga- angiogenic factors mediate capillary formation
tion of the ligament tissue, more fibrils become at the injury site. Platelet-derived growth fac-
uncrimped and oriented parallel to the direction tor (PDGF) and transforming growth factor-beta
of the applied load. This recruitment of fibrils (TGF-beta) also stimulate migration, differentia-
gradually stiffens the ligament tissue. tion, and matrix synthesis of endothelial cells and
fibroblasts, including myofifibroblasts.
In the maturation phase of the wound healing,
fibroblasts secrete extracellular matrix including
type I and type III collagen. During the early matu-
ration phase, disorganized collagen deposition is
observed with numerous fibroblasts. As the scar
matures, type I collagen production and deposi-
tion predominates. Remodeling of the scar occurs
by continuous degradation and synthesis of extra-
cellular matrix.

Biomechanical evaluation
after acute ligament injuries
Fig. 3 – A force-elongation curve. There are three regions that are com-
monly used to describe a force-elongation or stress-strain curve. The first The healing of extra-articular ligament injuries has
region is termed the “toe region” and elicits a non-linear increase in load been extensively studied over the decade using
as the tissue elongates. The second region represents the linear region of the MCL of the knee (8,14–18). The healing of the
the curve. In the third region, isolated collagen fibers are disrupted and MCL after sharp transaction and mop-end inju-
begin to fail. ries has been studied. These experimental stud-
Basic science of ligament healing 45

ies indicate that injuries to the MCL heal well in a (24–27). A biomechanical study using a rabbit
variety of animal models. Outcomes after surgical model showed that ultimate failure load of the
and non-surgical treatment of mop-end tears have femur-ACL-tibia complex is less than 50% of the
not been signifificantly diff
fferent. An experimental normal complex even 12 weeks after incomplete
study using a rabbit model shows that the ulti- tears (Fig. 4) (28).
mate failure load of the femur-MCL-tibia complex
reaches approximately 70% of the normal complex
at 12 weeks after either surgical or non-surgical
treatment of mop-end tears (18). These Th findings ACL graft healing in animal models
have been supported by a clinical study of isolated
MCL injury, wherein conservative treatment was The histologic structure of tendon grafts after ACL
preferable to operative intervention (20–22). reconstruction has been extensively evaluated
In contrast to the case in the MCL, it is well known using animal models. Arnoczky et al. observed a
that ACL injuries poorly heal (23). The periliga- synovial membrane with an abundant blood supply
ment environment and local mechanical factors at 4 weeks and central avascular necrosis around
may be responsible for the poor healing potential the patellar tendon (PT) graft at 6 weeks after ACL
of the ACL. In the ACL, vascular response is pro- reconstruction in the canine model (29). They also
fuse after its injury, but a stable fibrin
fi clot at the found that the central area was revascularized at
injury site is not maintained (4). Dilution of the 5 months, and their grafts appeared similar to an
hematoma by synovial fluid fl inhibits clot forma- ACL at 1 year. Amiel et al. showed central PT graft
tion, which initiates the healing response. Intrin- acellularity at 2 weeks, with cellular repopulation
sic diff
fference in cell populations in the ACL and from 3 to 6 weeks in a rabbit ACL reconstruction
MCL may also aff ffect their healing potentials after model (5). At 30 weeks after ACL reconstruction
their injuries. Cells isolated from the ACL demon- with a PT graft, the cell size and shape and the ori-
strate lower rates of proliferation and migration entation of the collagen bundles in the graft were
in culture, in comparison with cells from the MCL similar to those in a normal ACL. In a separate
report, Amiel et al. showed that the PT fibroblast
could not survive in a synovial environment and
that the PT graft was repopulated with fi fibroblasts
of a synovial origin (30). Ballock et al. reconstructed
rabbit ACLs with a PT graft and found an irregular
crimp pattern as late as 52 weeks after surgery,
with a cellular appearance similar to that of an ACL
Fig. 4 – (A) A schematic diagram of the operative procedure to create the (31). Concerning hamstring tendon graft, Grana
incomplete ACL tear. The distance between the two lines was measured at 90° et al. described the histologic changes within the
of knee flexion under anterior drawer force of 10 N (a).<Comp: Make changes intra-articular segment of a hamstring tendon
in figure label in the artwork as well.> It was approximately 5 mm. The anter-
omedial and posterolateral half of the right ACL was transected with a scalpel
autograft during the initial 52 weeks after surgery
at the proximal and distal one-third levels, respectively (b and c). An anterior (32). While the grafts remained viable at all time
drawer force is applied for 5 min, so that the ACL was elongated 2 mm (d). The periods, they found relative central acellularity at 4
ACL becomes slack after the anterior drawer force is removed (E). weeks, with repopulation of this region with spin-
dle cells at 8 weeks, and that the number of cell
nuclei in the hamstring tendon graft was similar
to that of the normal ACL at 52 weeks in spite of
some variation in the size and shape of the fibro-fi
blast cell nuclei. The remodeling of autologous ten-
don grafts used for ACL reconstruction is essential
for the clinical outcome after ACL reconstruction,
but the first 7 weeks of remodeling are associated
with an extensive decrease of the tensile strength
of the graft (33).
After harvesting for ACL reconstruction, autolo-
gous tendon grafts are separated from the circu-
lation, and the tissue becomes necrotic, followed
by ingrowth of a hypercellular and hypervas-
Fig. 4 –(B) Averaged load-elongation curves for the femur-ACL-tibia com- cular reparative tissue (29,30,34). Hypoxia is a
plexes after the incomplete ACL injury. Ultimate failure load of the femur- known potent stimulator for VEGF expression in
ACL-tibia complex is less than 50% of the normal complex 12 weeks even solid tumors (35), and thus it seems likely that
after incomplete tears. (From Ref. 27.) decreased oxygen tension at the transition to the
46 The Traumatic Knee

necrotic part may stimulate VEGF expression also VEGF mediates angiogenesis in the intra-articular
in tendon grafts after ACL reconstruction. We tendon graft in an early remodeling phase after
investigated temporal changes in the relationships the ACL reconstruction. This fact shows that VEGF
between VEGF expression, fibroblast proliferation, produced by the fibroblasts
fi induces revasculariza-
and angiogenesis in the PT graft at the early phase tion in the graft and implied that VEGF application
after ACL reconstruction in the rabbit model. We is a potential strategy to accelerate angiogenesis in
showed that VEGF was highly expressed in pro- the graft after ACL reconstruction.
liferating extrinsic fibroblasts
fi at 2 and 3 weeks
(Fig. 5A and B) (36). From 4 weeks, although the
ratio of VEGF-positive cells was reduced in the
graft, angiogenesis still continued to be enhanced Human studies on ACL graft healing
(Fig. 5A and C). In this period, vascular endothe-
lial cells mainly produced VEGF, which might con- All animal models have certain limitations, such as
tribute to promote localized angiogenesis. Con- the diffi
fficulty to replicate today’s refi
fined techniques
cerning VEGF expression in the grafted tendon at with optimized graft placement and sufficient
ffi fixa-
the long term after ACL reconstruction, Peterson tion, which might affect
ff the mechanical forces that
et al. (37) studied the expression of VEGF 6–104 are transmitted to the graft and its ensuing the
weeks after an ACL reconstruction model in sheep. remodeling and healing of the graft. Also, limita-
They showed there was strong immunostaining tions exist in the control of the weight bearing after
for VEGF in the synovial and subsynovial tissue in the surgery in the animal models. Th Therefore, it is
the periphery of the graft and within the invading important to understand that differences
ff between
reparative tissue at 6 weeks. At 24 weeks, how- the results of graft healing studies in animal mod-
ever, the intensity of VEGF immunostaining was els cannot be directly applied to the human ACL
decreased. At 52 and 104 weeks, grafts were largely patients. Several human biopsy studies found that
VEGF negative. These findings have suggested that the remodeling activity of human ACL grafts dur-

Fig. 5 – Temporal changes in the relationships between vascular endothelial growth factor (VEGF) expression, fibroblast proliferation, and angiogenesis in
the patellar tendon (PT) graft at the early phase after ACL reconstruction in the rabbit model. (A) Expression of VEGF in the PT graft at 2 and 8 weeks (×25);
(B) expression of proliferating cell nuclear antigen (PCNA) as a marker of cell proliferation in the PT graft at 2 and 8 weeks (×25); (C) expression of CD31 as a
marker of the vascular endothelial cell in the PT graft at 3 and 8 weeks (×25). (From Ref. 34.)
Basic science of ligament healing 47

ing the first

fi 3 months is diff fferent from the healing mine the mechanical characteristics of the bone-
graft in animal models (38,39). Although the previ- graft-bone complex. Several animal experimental
ously described healing process of animal models, and clinical studies have shown that tendon graft
i.e., graft necrosis, recellularization, revascular- heals within the bone tunnel by formation of a
ization, and matrix remodeling, are also found in bone-graft interface. Animal experimental studies
human ACL graft biopsies, the remodeling activity on tendon-bone healing are based on two differ- ff
of human ACL graft is not so drastic. Rougraff ff and ent models: an extra-articular model and an intra-
Shelbourne found viable intrinsic cells in human articular model. In the extra-articular model, the
biopsy specimens from the graft at all time points tendon is detached from one of its insertions and
between 3 and 8 weeks after ACL reconstruction fixed within a drilled tunnel of an adjacent bone. In
(39). Large areas of the human ACL graft seem to the intra-articular model, an ACL reconstruction is
stay unchanged, displaying tendinous structure performed using a free or pedicle tendon graft. The
with normal collagen alignment and crimp pattern. extra-articular model does not consider the biolog-
Neovasucularization was also found but did not ical stimuli of the intra-articular environment that
seem to be excessive as in the animal model. may affffect graft healing within the bone tunnel.
Since free tendon grafts are separated from their Recent studies using the extra-articular model
vascular supply during harvesting, ingrowth of new showed that tendon graft heals within a bone
blood vessels is an essential step for the process of tunnel by formation of an indirect-type interface
tendon graft remodeling (29). Yamagishi et al. (40) with fibrous tissue containing perpendicular col-
measured surface blood fl flow in ACLs reconstructed lagen fibers resembling Sharpey fibers penetrat-
with a bone-PT-bone autograft using laser Doppler ing into the bone. In a biomechanical study, the
flowmetry in clinical cases. They found signifi ficantly healing tissue at the bone-tendon interface was
high blood flow
fl values for the reconstructed ACL not mechanically competent until 8 weeks after
at 6 and 12 months, and a gradual return to near surgery (43).
normal values for the reconstructed ACL 18 months Animal experimental studies using intra-articular
after surgery. Shino et al. (41) also measured surface models of ACL reconstruction with single or double
blood flow in allografts after ACL reconstruction strands of tendon graft showed that an ACL graft
and examined their histology through biopsy speci- heals within the bone tunnel by formation of an
mens procured during second-look arthroscopy. indirect-type junction with collagen fibers
fi resem-
They found signifi ficantly high blood flow values for bling Sharpey fibers
fi perpendicular to the tunnel
the reconstructed ACL at 6 months, and a gradual wall (Fig. 6). Goradia et al. (44) reported that in a
return to near-normal values for the reconstructed sheep ACL reconstruction model using a doubled
ACL 12 months after surgery. semitendinous tendon graft, graft failure occurred
Although human biopsy studies showed substan- by pullout from the bone tunnel up to 12 weeks
tial diff
fferences from animal models for the prolif- after surgery and stated that a semitendinosus
eration phase, the matrix remodeling phases seem tendon graft has not completely healed within the
to be similar in both models in terms of biological
progression. Analysis of the biopsies of human PT
graft by Rougraff ff et al. (39) found that degenera-
tion of the graft increases until 6–10 months and
only slowly disappears between 1 and 3 years post-
operatively. Several biopsy studies confirmed
fi that
ACL grafts show a replacement of large-diameter
fibrils by large-diameter fibrils, which does not
change even after more than 2 years after ACL
reconstruction. Recently, Delay et al. (42) reported
a human ACL reconstruction case in which the core
portion of the PT graft still remained necrotic at
18 months after surgery.

Graft-tunnel healing after ligament

reconstruction in animal models Fig. 6 – Histological appearance of the tendon graft at 12 weeks after ACL
reconstruction in the dog. A tendon graft heals within the bone tunnel
Tendon graft healing within the bone tunnel is one by formation of an indirect-type junction with collagen fibers resembling
of the most important factors affffecting success of Sharpey fibers to the bonny tunnel wall (B) (H&E, original magnification
ligament reconstruction, as it contributes to deter- ×100). (From Ref. 43.)
48 The Traumatic Knee

bone tunnel for as long as 3 months after the ACL resembling Sharpey’s fibers
fi and immature woven
reconstruction surgery. Concerning the healing bone were seen between the tendon and the bone
process of ACL grafts with bone plugs within bone wall. The tendon-bone interface was composed of
tunnels, the healing process of the tendinous por- a continuous layer of Sharpey-like fibersfi after 1
tion of the graft within the bone tunnel is consid- year, although no contact was seen at the tendon-
ered to be diff
fferent from the healing process of the bone interface in three cases. Concerning the com-
bone plug (45). TheTh intraosseous tendinous por- parison between the interference screw fi fixation
tion of the graft heals by forming collagen fi fibers and the suspension fixation for hamstring tendon
that resemble Sharpey fi fibers perpendicular to the graft, Nebelung et al. (48) evaluated biopsies from
tunnel wall and appear well organized by 3 months the femoral tunnel in four patients at 6–14 months
after surgery. On the other hand, the bone plug of after ACL reconstruction with a suspension device
the bone-tendon-bone graft incorporation at the (Endobutton or TransFix) and one with an inter-
tunnel wall occurs through a progression of necro- ference screw. In patients with a suspension device,
sis, resorption, and remodeling. However, the granulation tissue without continuity of collagen
native insertion site of the bone-tendon-bone graft fibers was observed at the tendon-bone interface.
shows degeneration of the fibrocartilaginous layer In contrast, a metaplastic fibrocartilage was noted
by several weeks during the bone plug remodeling. at the tendon-bone interface in patients with no
Concerning biomechanical comparison between suspension device.
tendon-bone and bone-bone healing, animal Regarding bone-PT-bone graft healing, Petersen
experimental studies using the intra-articular ACL and Laprell (49) examined histological findings of
reconstruction model show that bone-bone healing biopsies at ACL revision surgery and reported that
occurs more rapidly than tendon-bone healing. Up bone-PT-bone graft healed within bone tunnel by
to a few weeks, both soft tissue tendon and bone bone plug incorporation and a direct-type insertion
plug tendon grafts fail by pullout from the tunnel. of the native bone plug-tendon junction was main-
During several weeks after surgery, the bonding tained. However, Ishibashi et al. (50) showed that
between the bone plug and the tunnel wall appears the original insertion of the native bone plug-ten-
mechanically stronger than that between the soft don junction was not observed in biopsies that were
tissue tendon and the tunnel wall, although the obtained at the revision surgery more than one year
mechanical superiority of bone-bone healing is no after the initial ACL reconstruction surgery.
more signifificant by 3 months after surgery (45). All above-mentioned studies on graft-tunnel heal-
Therefore, the fixation method for soft tissue ten-
Th ing after human ACL reconstruction are based on
don graft is considered to be more important than histological examination of biopsy from cases that
that for the bone-tendon graft during the first
fi sev- underwent revision surgery due to an ACL graft
eral weeks after ACL reconstruction. failure. There are high possibilities that failure of
the ACL graft might aff ffect their histological find-
ings and that a poor healing process of the graft
within the bone tunnel might induce the ACL graft
Graft-tunnel healing after ligament failure. Therefore, we should take these possibili-
reconstruction in human biopsy studies ties into account for the interpretation of the find-
ings of these biopsy studies on graft-tunnel heal-
Although a certain number of animal studies were ing in human ACL reconstruction.
reported on graft-tunnel healing, investigation of
graft-tunnel healing in human ACL reconstruc-
tion is very limited. A two-case study reported on
biopsy at the graft-bone interface in the patients Summary
who underwent revision surgery for graft failure
by trauma at 6 and 10 months after ACL recon- Healing of an injury to ligament tissues requires
struction using doubled hamstring tendon graft complex interactions between cells, extracellular
with metal interference screws (46). The study matrix, growth factors, and mediators of the inflam-
showed graft integration by collagen fibers
fi resem- matory response. Wound healing can be basically
bling Sharpey’s fibers
fi between the tendon and the divided into infl
flammatory, proliferative, and mat-
bone wall. Another study reported the histological uration phases. Animal experimental studies indi-
findings of 12 biopsies from the patients under- cate that injuries to the extra-articular ligament,
going arthroscopy with various sorts of reasons such as an MCL of the knee, heal well. In contrast
between 3 and 20 months after ACL reconstruc- to the case in the MCL, the periligament environ-
tion using doubled hamstring tendon graft with ment and local mechanical factors may be respon-
a suspension fixation device (TransFix) (47). At sible for the poor healing potential of the ACL.
5–6 months after surgery, some collagen fi fibers After harvesting for ACL reconstruction, autolo-
Basic science of ligament healing 49

gous tendon grafts are separated from the circula- 12. Woo SL-Y, Suh JK, Parsons IM, et al. (1998) Biological
tion, and the tissue becomes necrotic. Therefore, intervention in ligament healing eff ffect of growth factors.
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Clinical Basis
Chapter 6

T.E. Hewett, B.T. Zazulak,

T. Krosshaug, R. Bahr
Clinical basis: epidemiology,
risk factors, mechanisms of injury,
and prevention of ligament injuries
of the knee

Introduction romuscular control about the knee takes place with

maturation in female athletes. In sports, the high-

nee ligament injuries can be devastating to an est ACL injury incidences occur during participation
athlete’s career and pose long-lasting deleteri- in basketball, soccer, and team handball, especially
ous eff
ffects in the form of knee osteoarthritis among top-level female athletes that compete in
(1). We will begin with a review of the epidemiology these sports (Table 1). Th
This trend is similar for knee
of athletic knee ligament injury in general. Further- injuries, in general, as well (Table 2). Another sport
more, we will review the mechanisms of injury and with a high risk of knee injuries (and ACL injuries)
relative risk factors for these common athletic inju- is skiing. However, since the incidence is typically
ries. This chapter will also review the epidemiology,
mechanism, risk factors, and prevention of knee Table 1 – Risk of ACL injury by sport. The numbers reported are average
joint injuries in general; however, it will focus on estimates based on published studies.
one of the most serious knee injuries experienced
during participation in sports: disruption of the Sport Competition Training Comments
anterior cruciate ligament (ACL). This injury may incidencea incidencea
not be the most common ligament injury experi- Basketball 0.28–0.40 Ɋ b
0.14 Ɋ NBA & WNBA
enced in sports; however, it is one of the most seri- 0.08–0.16b ɉ b
0.04 ɉ (6–8)
ous in terms of absence from sport, pain, disability, *NCAA data 2006
and increased risk of development of osteoarthritis (6,7)
about the knee joint (2). We will therefore discuss Soccer 0.33–2.2 Ɋ b
0.10 Ɋ *NCAA data 2006
methods for prevention of knee ligament injuries, 0.12 ɉ b
0.04 ɉ (6,9)
which currently is the only 100% efficacious
ffi inter- Team 1.3–2.8 Ɋ 0.03Ɋ Elite level (1)
vention for long-term health of the knee joint. handball 0.23 ɉ –
Volleyball 0.19 Ɋ 0.05 Ɋ NCAA data 2006
(Agel J, personal
Epidemiology of knee ligament injury in sports Alpine 4.4Ɋ c – ** per 100,000
skiing 4.0 ɉ c – skier days (10),
The objective of this section is to review the published Ɋ twice of ɉ in
literature regarding knee ligament injuries in sports, some studies
addressing the following questions: what is the inci- Field 0.15 Ɋ 0.05 Ɋ NCAA data 2006
dence of knee ligament injury in the athletic popula- Hockey (Agel J, personal
tion? How does knee ligament injury incidence vary communication)
by gender, age, and sport? Of all knee ligaments, the Ice hockey 0.14 Ɋ – NCAA data 2006
ACL is the ligament that has been most investigated. 0.21 ɉ 0.02 ɉ (Agel J, personal
There is evidence in the literature that ACL injuries communication)
vary by gender, by age, and by sport. A sex difference
ff Wrestling 0.70 ɉ 0.06 ɉ NCAA data 2006
in knee injury risk is apparent in high-risk landing (Agel J, personal
and cutting sports, where female athletes sufferff ACL communication)
injuries more often than their male counterparts a
Incidence is reported for adult, competitive athletes as the number of
taking part in the same sports at the same level of injuries per 1000 h of training and competition or per 100,000 skiing days
competition (3,4). Evidence also suggests that, with in alpine skiing.
growth and development, the incidence of knee liga- b
Explanation for asterisk needed.
ment injury increases in females (5). Decrease in neu- c
Explanation for double asterisk needed.
54 The Traumatic Knee

Table 2 – Risk of knee injury by sport, age, and sex. The numbers reported are average estimates based on published studies.
Sport Age group Incidence in femalesa Incidence in malesa References
Basketball 14–18 years 0.71 AH 0.31 AH (11)
Collegiate 0.37 AE 0.25 AE (12)
Adult 4.4 AE 2.5 AE (7)
Soccer Collegiate 0.40 AE 0.33 AE (13)
Collegiate 1.6 AE 1.3 AE (3)
7–50+ 0.13 AH 0.094 AH (14)
Field hockey Collegiate 0.30 AE NA (15)
Lacrosse Collegiate 0.20 AE 0.20 AE (16,17)
Gymnastics Collegiate 0.53 AE NA (18)
Volleyball Collegiate 0.22 AE NA (19)
Football Collegiate NA 1.58 AE (20)
Incidence is reported as the number of injuries per 1000 athlete hours (AH) of training and competition or 1000 athlete exposures (AE). NA: data not

reported as the number of injuries per 100,000 skier A study of Australian football athletes reported
days in studies on skiing injuries, it is not possible to that the risk of sustaining non-contact ACL inju-
compare these figures to those from team sports. ries increased during high-evaporation and low-
rainfall periods (23). Studies of soccer athletes
reported that competing on artificial
fi turf does not
increase the risk of knee injuries compared with
Key risk factors for knee injuries natural grass (24). In contrast, recent studies of
professional American football athletes suggest
A large number of studies have investigated poten-
that the incidence of ACL injuries may be greater
tial risk factors for severe knee injuries, and a major-
on the new artifi ficial turf designs in comparison to
ity of this work has focused on ACL injuries. When
the older turf designs (25). In the sport of Euro-
considering athletes that compete at the elite or
pean team handball, it was shown that the risk of
collegiate level, the risk of suffffering an ACL injury
ACL injury was 2.4 times greater when competing
ranges between 2 and 8 times greater for women
ficial floors (with an increased coeffi
on artifi fficient
compared to men for similar sports at similar levels
of friction) compared with wooden floors (26).
of competition, and consequently, there appears to
Earlier studies of American football athletes have
be a consensus across sports that gender is a risk fac-
shown that the use of longer cleat lengths and an
tor for ACL disruption (21). However, there remains
associated higher torsional resistance at the foot-
a signifi
ficant knowledge gap concerning the risk fac-
turf interface places these athletes at increased
tors for serious knee injuries such as an ACL disrup-
risk of suff
ffering knee injuries (24). There is little
tion. This is because only a few well-designed pro-
doubt the shoe-playing surface interface is impor-
spective studies are available, and most studies have
tant to consider when developing intervention
assessed only one factor in isolation. Considering
strategies to reduce the incidence rate of serious
that the risk factors for ACL injury are multifacto-
knee injuries.
rial (e.g., multiple risk factors act in combination to
increase an athletes risk of suffffering an ACL injury)
(22), this approach is not appropriate to assess Knee bracing
how risk factors act in combination to increase an Two investigations have studied the effect ff of pro-
individuals risk of suffffering a severe knee ligament phylactic knee bracing on American football ath-
injury. Further, a large majority of these studies letes. The first study found signifi
ficantly fewer medial
have identifi fied sex diff
fferences in anatomy as well collateral ligament (MCL) injuries occurred in ath-
as hormonal and neuromuscular function; however, letes who used prophylactic bracing in comparison
they fail to relate these differences
ff to the risk of suf- to those who did not use braces (27); however, the
fering a severe knee ligament injury. ffect of prophylactic bracing on ACL injuries could
not be determined because of the small sample size.
In contrast, the second study did not find fi statisti-
External risk factors cally significant
fi diff
fferences between braced and
unbraced athletes in terms of the risk of sustaining
Surface MCL injuries (27). Additional research is needed in
The shoe-surface interaction has been studied this area to establish the eff ffect that prophylactic
as an ACL injury risk factor in different
ff sports. braces have on knee injuries.
Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 55

Ski bindings studies have not found such a relationship (35,36).

Although alpine ski bindings have been devel- The data on BMI appear to be inconsistent, making
oped to eff ffectively protect skiers from tibia and it diffi
fficult to establish reliable conclusions.
ankle fractures, the present-day alpine ski binding
designs are inadequate for preventing ACL disrup- Genetics
tions, even when the bindings function as designed Two case-control studies reported that familial
and are properly adjusted (28). In a large prospec- tendency is a risk factor for ACL injury (37,38).
tive study of ACL-deficient
fi professional alpine ski- Athletes who suffffer an ACL tear are twice as likely
ers, the risk of sustaining a subsequent knee injury to have a relative with an ACL tear compared with
(e.g., injury to other structures about the knee age-, sex-, and sport-matched controls.
such as articular cartilage and the menisci) was 6.4
times greater for non-braced skiers in comparison Race
to braced skiers (29).
In a recent 4-year cohort study, it was found that
white European American athletes were 6.6 times
Competition vs. training more likely to suffer
ff an ACL tear compared with
Participating in a game appears to be a strong risk other ethnic groups (39).
factor for knee injury. Studies of European team
handball athletes have shown that the relative Knee alignment
risk of sustaining an ACL injury is approximately
30 times greater during competition than during The Q angle of the knee has been studied as a pos-
training (30). As can be seen from Table 1, the dif- sible explanation for the gender difference
ff in ACL
ference in injury risk between training and compe- injury rates, with the rationale that high Q angles
tition is a consistent finding across sports. At this may be associated with excessive valgus loading of
point in time, the explanation for this large differ-
ff the knee. These studies consistently report higher
ence has not been determined, but the most likely Q angles in females (40–42). A case-control study
explanation is that the intensity of play is much reported that the mean Q angles of athletes sus-
higher during competition and that during train- taining knee injuries were signifi ficantly larger
ing much time is spent on basic training activities than the mean Q angles for athletes who were not
with a low risk of injury. injured (14° vs. 10°) (43). In contrast, others have
reported that the risk of suff ffering a knee injury
was not related to anatomical alignment differ- ff
Internal risk factors ences such as Q angles (44). One study reported
that pelvic width to thigh length ratio, and not Q
angle, predicts dynamic valgus angulation about
Previous injury the knee during the single leg squat (45). It has
Recent studies have suggested that having a pre- also been shown that a long femur to tibia ratio
vious injury may be a risk factor for subsequent may be a risk factor for ACL injuries in competitive
injury – either a rupture of the ACL graft, an ACL alpine skiers (46).
rupture to the contralateral knee, or another type
of acute or overuse knee injury (31–33). Intercondylar notch width
Age One of the most studied factors in relation to ACL
injury is the femoral intercondylar notch width.
Although there appears to be a consensus that Several investigators have hypothesized that a nar-
the risk of suffffering an ACL injury increases for row intercondylar notch or notch width index (e.g.,
female athletes during their growth spurt, there the ratio of the width of the femoral notch to the
are no investigations that have included age as a width of femoral condyles when observed via x-ray
potential risk factor in the analysis of serious knee in a coronal plane view) may predispose athletes to
injuries in skeletally mature athletes. Similarly, no an increased risk of ACL injury (47–50). One cause
investigations of the eff
ffect of age on the likelihood could be that a narrower femoral notch is associ-
of suff
ffering a knee injury in skeletally immature ated with a smaller, weaker ACL. Another possi-
athletes exist. bility is that impingement of the ACL against the
femoral intercondylar notch may be more predom-
Body composition inant when the notch is narrow. This may induce
An increased body mass index (BMI) has been micro tears of the ligament during participation
found to be associated with an increased risk of in athletics that subsequently progress to macro
ffering ACL injuries in female cadets attending tears that weaken the ligament and predispose it
the US Military Academy (34). However, other to an increased risk of a complete tear. Research is
56 The Traumatic Knee

needed to delineate the role of notch impingement The use of an athlete’s self-report of menstrual his-
as an ACL injury risk factor. One review study (51) tory is inadequate to determine the phase of cycle
and two prospective cohort studies (48,50), as well at the time of injury (60), and findings from such
as several other lesser quality studies (52,53), have studies reveal conflflicting results (21,60). Review
found that athletes with a decreased femoral notch of studies that have used hormone measurements
width are at increased risk of suff ffering an ACL reveals that the risk of suff
ffering a non-contact ACL
injury. There are, however, also several studies that injury is greater during the pre-ovulatory phase of
do not show such an association (47,49,54), and the menstrual cycle in comparison to the post-ovu-
as a consequence, it remains unclear how notch latory phase (61).
width geometry, or notch width index, is related to
increased risk of suff
ffering an ACL injury. Patella tendon-tibia shaft angle
One of the most investigated hypotheses in recent
ACL properties years is whether a quadriceps contraction per-
Th size and material properties of the ACL are fac-
The formed with the knee near extension can create a
tors that may infl fluence the risk of this ligament force of suffi
fficient magnitude on the patellar ten-
tearing. It has been shown that ACLs, in females don such that it produces an anterior translation
are smaller than in males when normalized for of the tibia relative to the femur and ruptures the
body weight (47). In addition, it has been reported ACL (63,64). The patella tendon-tibia shaft angle
that female ligaments have lower strain and strain (PTTSA) is the sagittal plane angle between the
energy density at failure as well as 22.5% lower tibia (ankle to knee joint) and the line of action
modulus of elasticity (55). However, at the current of the patellar tendon. When the knee is near full
point in time, no risk factor studies have consid- extension, an increased PTTSA produces a larger
ered these variables. On the other hand, there are magnitude of anterior-directed force on the tibia
studies that have established increased anterior and increases the loads transmitted to the ACL. It
knee laxity as a risk factor for females (56), and this has been shown that females have greater PTTSA
may be a result of differences
ff in the size and mate- throughout the range of knee flexion
fl compared to
rial properties of the ACL. It is important for us males, and that this angle is greater when the knee
to point out that these studies are relatively small, is close to full knee extension. However, no risk
and such factors can only explain a relatively small factor studies have included PTTSA in the analy-
proportion of the variance in ACL injury risk. Gen- ses. The same is true for the slope of the tibial
eralized joint and ligament laxity have also been plateau in the sagittal plane. An increased slope
proposed as risk factors for knee ligament injuries; of the plateau will generate an increased anteri-
however, most of these studies have evaluated the or-directed force on the tibia when compression
ffect on these variables on all lower extremity forces, such as that produced during landing or
injuries as a group and not knee ligament injuries plant and cut maneuvers, are produced across the
in isolation. A few exceptions exist, and these stud- knee (65).
ies suggest that increased generalized joint laxity
and increased hyperextension of the knee may be
Landing mechanics
associated with increased risk of suff ffering an ACL
injury (34,57). Another explanation for the gender difference
ff in
ACL injury rate is that females may land with the
Foot pronation knees in a more extended position compared with
men, creating a higher PTTSA and possibly gen-
It has been suggested that foot pronation may lead erating an increased anterior-directed shear force
to anterior tibial translation, and subsequently on the tibia (66,67). Although several studies have
sprain the ACL; however, the results are conflict-
fl investigated this knee flexion hypothesis, there
ing. Three case-control studies found a relation- is no consensus in the literature. In a recent pro-
ship between foot pronation/navicular drop and spective risk factor study of 205 female athletes in
ACL injuries, whereas one found no such relation- soccer, basketball, and volleyball, where knee flex-
ship (56,58,59). ion angles produced during jump landings were
assessed, no significant
fi diff
fferences were found
Hormone levels between injured and uninjured subjects (31). The Th
To determine how diff fferent phases of the men- same study showed that valgus motion and valgus
strual cycle aff
ffect ACL injury risk, it appears neces- moments predicted ACL injuries with a sensitivity
sary to accurately describe the hormone milieu with of 78% and a specifi ficity of 73%. Also, leg domi-
serum or urine-based measures of hormone con- nance was studied, but this factor was not found to
centrations and then use these data to accurately be associated with risk of suffffering an ACL injury.
identify the phase of the cycle when injury occurs. It should be mentioned that only nine ACL injuries
Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 57

were included in this study, so new studies should injury risk factors, and consequently, it is not pos-
be conducted to confirm
fi these findings. sible to determine the relative importance of these
factors at this point in time.
Other neuromuscular factors It should be noted that factors such as anatomic
Several neuromuscular measures have been pro- alignment and ligament properties are not easily
posed as possible risk factors for ACL injury. modififiable, and therefore, direct intervention on
Quadriceps dominance, ligament dominance, limb such factors may be difficult.
ffi Nevertheless, if we
dominance, muscle reaction time, time to peak can identify individuals at risk (e.g., athletes who
force, muscle stiff
ffness, muscle strength, poor neu- anatomically are prone to ACL injury), it may be
romuscular control of the trunk, and fatigue are all possible to initiate individualized injury preven-
factors that may have an influence
fl on an athlete’s tion measures. It has been shown that combining
risk of suff
ffering an ACL injury (22,68). It has been two or more risk factors such as notch width and
shown that females exhibit greater quadriceps BMI results in a dramatic increase in the risk of
dominance and that they have less muscle stiffness
ff ACL injury (relative risk 26.2) compared to having
and muscle strength compared to males. However, only one of the two factors in isolation (relative
none of these factors have been studied as ACL risks of 3.5 and 4.0, respectively) (34).

Table 3 – Internal and external factors for knee ligament sprains in different sports. The numbers reported are average estimates based
on the studies available.
Risk factor Relative risk Evidence Comments
External risk factors
Surface 2–2.4×* + Few studies. Greater risk of injury when competing on higher friction
floors, but only for women.
Meteorological conditions 1.9–2.8× + Only one study. Non-contact ACL injuries more frequent during high
evaporation and low-rainfall periods.
Footwear NA + Only two studies. Shoes with longer cleats produced significantly
greater ACL injury rates.
Game vs. Practice 29.9× +(+) Higher ACL injury rate during competition.
Internal risk factors
Gender 2–8× ++ Risk of ACL injury is greater in women compared to men when
participating in the same sport at the same level of competition.
Previous injury 3.1–11.3× + Risk for new knee injuries in general as well as new ACL injuries, both in
the reconstructed and the contralateral knee.
Age NA - No studies were found that included age as a potential risk factor for
ACL injury
BMI 3.5× + Few studies. Higher risk of ACL injury for women with high BMI.
Conflicting results.
Familial tendency 2.0×* + Only two studies. Athletes with an ACL tear are 2 times more likely to
have a relative with an ACL tear.
Race 6.6×* + Only one study. White European American players more susceptible to
ACL tears compared with other ethnic groups.
Q-angle NA + Higher Q-angle in females. Conflicting results.
Leg length NA + Long femur relative to tibia may be a risk factor in skiers. Wide pelvis
relative to femur predicts dynamic valgus in one-legged squats
Intercondylar notch width index 3.7–6.0× + Small notch width index may lead to increased risk of suffering an ACL injury.
Several positive studies, but also some studies with conflicting results
Ligament cross-sectional area NA - No risk factor studies. Relative larger cross-sectional area in males after
adjusting for body weight
Ligament material properties NA - No risk factor studies. Female ligaments have lower strain and strain
energy density at failure, as well as lower modulus of elasticity
compared to males
Anterior knee laxity 2.7× + Only two studies. The larger, prospective study found a 2.7 fold
increased risk for ACL injury in females with A-P knee laxity values
greater than 1 SD of the mean. A-P knee laxity had no effect on risk of
ACL injury in males.
58 The Traumatic Knee

Risk factor Relative risk Evidence Comments

General joint laxity 2.8× + Few studies. Females exhibit greater joint laxity than males. Skiers with
increased hyperextension of the knee are in significantly increased risk
of suffering ACL injury.
Patella tendon – tibia shaft NA - No risk factor studies. PTTSA is greater in females compared to males
angle (PTTSA)
Foot pronation/navicular drop NA + Three studies found a relationship, whereas one study found no
Phase of menstrual cycle 3.2×* + Studies that have accurately measured phase of cycle with serum or
urine based assays of estradiole and progesterone have observed a
greater proportion of ACL injuries in the preovulatory phase of the
menstrual cycle in comparison to the post-ovulatory phase. One
study of recreational alpine skiers found the odds ratio of suffering an
ACL disruption was 3.2 times greater during the preovulatory phase
compared to the postovulatory phase of the menstrual cycle.
Knee flexion during landing NA - Only one risk factor study that showed no relationship. Conflicting
results among studies looking at gender differences.
Valgus motion and valgus NA + Only one risk factor study. Valgus moments have a sensitivity of 78%
moment during landing and a specificity of 73% for predicting ACL injury status.
Leg dominance during landing NA - Only one risk factor study, but no significant effect of this variable on
ACL injury risk. Females have greater side-to-side (leg dominance)
differences in knee loads
Quadriceps dominance NA - No risk factor studies. Females exhibit greater quadriceps dominance
than males.
Muscle stiffness NA - No risk factor studies. Females have lower muscle stiffness than males.
Muscle strength NA - No risk factor studies. Females have lower muscle strength than males.
Muscle reaction time NA - No risk factor studies.
Time to peak force NA - No risk factor studies.
Fatigue NA - No risk factor studies. No gender differences. Fatigue may alter the
neuromuscular control of knee biomechanics
Relative risk indicates the increased risk of injury to an individual with this risk factor relative to an individual who does not have this characteristic. A
relative risk of 1.2× means that the risk of injury is 20% higher for an individual with this characteristic.
Evidence indicates the level of scientific evidence for this factor being a risk factor for ligament sprains: ++, convincing evidence from high-quality
studies with consistent results; +, evidence from lesser quality studies or mixed results; ?, expert opinion without scientific evidence.
*Odds ratio and not relative risk.
NA, not available.

Injury mechanisms for knee injuries be supported by the leg that suff ffers an injury.
Previous studies have suggested that the knee
Much attention has been given to treatment of is near extension at the time of ligament injury
serious knee injuries, ACL and MCL disruptions (i.e., less than 30°) (26,57); however, recent stud-
in particular; however, very little is known about ies that have included a validation of the visual
the risk factors that predispose an athlete to these inspection method indicate that the knee is likely
ligament tears and the injury mechanisms that injured when it is in a position of greater fl
produce these debilitating injuries. During most (69,70). Although the majority of ACL injuries
Olympic sports, ACL injuries are commonly non- are non-contact by definition,
fi the movement pat-
contact in nature and can occur during plant and terns often involve perturbation by an opponent,
cut maneuvers (Fig. 1), but a high proportion of e.g., body contact prior to the injury (69). Even if
these injuries also occurs during landings (Fig. 2). a few details are known, we still lack vital knowl-
In basketball, landings are the most frequently edge about the injury mechanisms. A complete
reported mechanism for ACL injuries (69). biomechanical description should quantify whole
It is important to realize that while an athlete body and knee kinematics, loading directions and
may appear to land on both feet with body weight magnitudes, and the rate of application of exter-
equally distributed between legs, at the point nal and internal forces about the lower extremity
of impact the entire ground reaction force may (71).
Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 59

Fig. 1 – Frame sequence of a plant and cut team handball injury showing
the athlete at initial ground contact (A), at 40 ms (B), and at 100 ms (C),

Skiing injury mechanisms

Knee ligament injury mechanisms in traditional
alpine skiing have been investigated for some time,
and various injury mechanisms have been pro-
posed, both for ACL injuries and other ligament
injuries (72,73). Some knee injury mechanisms
are equipment related, such as when the back por-
tion of the ski boot acts to produce a “boot-induced Fig. 2 – Landing injury in basketball. The injured player is seen in white
anterior drawer” (e.g., an anterior-directed force shorts in the middle of the images at initial ground contact (A); 33 ms after
on the tibia that tears the ACL) or when the edge initial contact, corresponding to the approximate estimated time of rupture
of the ski is caught in the snow. (B); and 133 ms after initial contact (C).
Some injury mechanisms are associated with cer-
tain circumstances, such as backward fall, with the Previous studies on knee ligament injury mecha-
weight of the skier on the inner edge of the tail of nisms produced during alpine skiing have mainly
the ski resulting in a sharp uncontrolled inward used approaches such as athlete interview and
twist of the lower leg (Fig. 3). Th This scenario is visual inspection of injuries captured on video.
termed the “phantom foot mechanism” and is con- These approaches have methodological limitations,
sidered the most common ACL injury mechanism and there is need for improvements of the existing
in alpine skiing (74). injury mechanism descriptions (75).

Hypotheses for non-contact ACL injuries

Although gross biomechanical information about
serious knee injuries exists, detailed biomechani-
cal information (i.e., joint loading) is not known.
For injuries that are caused by a direct blow to the
knee, which is the case for many MCL injuries, the
loading patterns are more obvious. However, for
non-contact ACL injuries, difffferent hypotheses are
heavily debated in the scientifi
fic community.
Studies have shown that external tibial rotation
combined with valgus rotation with the knee in an
extended or partially fl
flexed position initiates ACL
strain as the ligament contacts and then impinges
against the medial aspect of the lateral femoral
condyle (Fig. 4) (76).

The ligament impingement theory

Fig. 3 – Drawing of the body position in the “phantom foot” injury mecha- The ligament impingement theory has also been
nism. The weight of the skier is on the inner edge of the tail of the ski result- suggested based on observations from video analy-
ing in a sharp uncontrolled inward twist of the lower leg. From [74]. sis studies (26). Although it remains unknown how
60 The Traumatic Knee

Quadriceps loading
Several cadaver studies have shown that quadri-
ceps loading strains the ACL when the knee is near
extension. It has been hypothesized that a vigor-
ous quadriceps contraction when landing on an
extended knee can produce high ACL strain values
(63,64). In this theory, contraction of the quadri-
ceps muscle group and subsequent engagement
of the patellofemoral joint produces a load on the
patellar tendon, which has an anterior-directed
angulation relative to the tibia when the knee is
near extension, and this generates a force on the
tibia with an anterior-directed component. As the
knee is moved from an extended to a flexed posi-
tion, the orientation of the patellar tendon relative
to the tibia moves from an anterior to a posterior
direction as does the corresponding direction of the
force produced by the quadriceps extensor mecha-
nism. Understanding this biomechanical relation-
Fig. 4 – A sidestep cutting maneuver may lead to valgus and external ship, studies have investigated if the gender differ-ff
tibial rotation. The solid arrow indicates a possible impingement of the ACL ence in ACL injury incidence can be explained by
against the intercondylar notch. the fact that females appear to land with their knee
and hip in a more extended position. The Th find-
ings from these studies confl flict. In actual injury
the ligament impinges against the medial aspect situations, females are found to be at signifi ficantly
of the lateral femoral condyle and strains the ACL, greater knee and hip flexion angles at initial con-
there is evidence that valgus loading of the tibia rel- tact with the playing surface and at the assumed
ative to the femur is likely an important aspect of point of injury in comparison to males (69). Th This
the loads applied to the knee during an ACL injury finding suggests that landing on straighter knees
(77). A recent prospective risk factor study showed may not be an important reason for the observed
that increased valgus loading when landing from a diff
fference in ACL injury incidence rates between
jump was associated with increased risk of suffer-ff males and females. Although a novel cadaver study
ing an ACL injury amongst soccer, basketball, and demonstrated that the quadriceps-induced ante-
volleyball athletes (31). Several studies also report rior drawer mechanism is capable of producing
that MCL injuries are frequently seen in combi- ACL rupture (63), this approach was criticized for
nation with non-contact ACL injuries, indicating not including ground reaction forces, which may
that valgus loading was present (78). Interestingly, act posteriorly on the tibia and help restrain ante-
laboratory-based motion analysis studies have dem- rior translation of the tibia. Three
Th mathematical
onstrated that females develop larger magnitudes model simulation studies of landing and plant and
of valgus and external torques about the knee when cut maneuvers, which included the eff ffect of ground
landing from a jump in comparison to males (79), reaction and hamstrings forces, all concluded that
suggesting that knee valgus loading may explain, at the anterior-directed shear force that acts on the
least in part, the larger incidence rate of ACL inju- tibia cannot generate the suffi fficient magnitude to
ries seen in females compared to males taking part rupture the ACL, even in extreme cases where ham-
in the same sport at the same level of competition. strings forces are non-existent (65,79,80). Still,
A recent video-based analysis study of actual ACL the results of these studies were quite different,
injury situations reported a large number of valgus possibly due to the fact that realistic modeling and
collapses about the knee for female athletes (69). simulation of the knee joint is challenging. In con-
This evidence suggests that valgus loading plays trast to the findings from mathematical modeling
an important role in many of the non-contact ACL studies, a recently published cadaver study dem-
injury situations, at least amongst female athletes. onstrated that anterior tibial translation and ACL
However, there are likely to be other forces and strain proportional to the applied quadriceps force
torques applied to the knee during injury, since it were generated when the ground contact forces
has been shown that pure valgus loading will rup- were also included. However, since the loading
ture the MCL first, then the ACL, and second, only was far from injury level, it is not possible to make
a limited number of MCL ruptures are found in firm conclusions regarding the quadriceps-induced
conjunction with non-contact ACL injuries. anterior drawer mechanism from this study. Fur-
Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 61

ther investigations are required to delineate the athletes. For the optimal design of knee interven-
role of quadriceps-induced anterior drawer loading tion programs, we can learn much from a system-
of the tibia in producing ACL injuries. atic analysis of the common components of the
published interventions, successful and unsuccess-
ful, designed to reduce knee injury risk in athletes.
Internal rotation Analyzing the common components of the most
ffective and least effffective programs is useful for
There are several factors that suggest internal rota- the development of eff ffective intervention proto-
tion of the tibia relative to the femur on a relatively cols. Hewett et al. performed a systematic review
extended knee could be a potential mechanism of of intervention studies designed to reduce knee
non-contact ACL injuries. First, cadaver and human injury risk in female athletes and revealed that
studies have shown that the ACL is strained when several programs appear to reduce ACL injury risk
torques are applied to internally rotate the tibia rel- (82). In contrast, other studies have failed to show
ative to the femur (81). Second, internal rotation is an effffect of neuromuscular training on the reduc-
frequently reported to be the mechanism of injury tion of knee injury rates or establish that they can
in athlete interview studies (30), in video analysis alter lower extremity biomechanics (83,84). Most
(26), as well as suggested from the associated clini- of what is known has come from studies of female
cal findings. Motion analysis studies of side step cut- athletes, as they are at increased risk of knee injury.
ting maneuvers usually show a dominance of inter- The mechanism of ACL injury may diff ffer between
nal tibial rotation during the stance phase. However, females and males, particularly with respect to
males are reported to exhibit this pattern to a larger the dynamic positioning and control of the knee,
degree than females, indicating that other loading as females demonstrate greater valgus collapse of
scenarios are likely associated with many female the lower extremity, primarily in the coronal plane.
non-contact ACL injuries. Hyperextension has also However, female athletes may serve as a working
been proposed as a possible mechanism, but this model for any athlete at increased risk of suff ffering
seems unlikely considering that such injuries have a knee injury. In this section, we will describe many
not been reported in any video analysis studies. of the prevention methods and neuromuscular
training programs and provide broad instructions
and guidelines for the exercises. In addition, we will
Conclusions review as many components of the successful, and
There is a need to develop better research meth- unsuccessful, programs as possible within the spe-
ods to investigate the mechanisms of serious knee cifi
fic purview of knee injury prevention in athletes.
injuries, particularly ACL injuries. Mathematical There appears to be a measurable eff ffect of neuro-
simulation models have the potential to include all muscular training interventions on the reduction
important aspects of an injury (e.g., ground reac- of severe knee and ACL injuries. A comprehensive
tion forces, tibiofemoral contact mechanics, and review of the literature revealed that fi five of six
neuromuscular control patterns) in a computer studies demonstrated that neuromuscular train-
environment, thus avoiding any hazard to athletes. ing reduced lower extremity injury risk, four of six
However, considerable challenges exist in generat- studies found that neuromuscular training reduced
ing valid models that replicate joint biomechanics serious knee injury risk, and three of six reported
at the time of injury. Therefore,
Th such model-based decreased knee and ACL injury risk (82). Below we
analysis should be accompanied by video analysis summarize the components of the most successful
as well as clinical studies looking at the associated programs. Plyometric training and biomechanical
joint damage (arthroscopy, radiology, CT, MRI), analysis of landing, cutting, and jumping tech-
cadaver testing, motion analysis of similar “close- niques were common components of the studies
to-injury situations,” and in-vivo studies where that were effffective at reducing the risk of knee and
ligament strain and forces are measured. ACL injury in athletes.

Plyometrics is an important component for reduction

Preventing knee injuries among athletes of ACL injury risk in athletes
The evidence for including a plyometric component
Developing “optimal
“ l” neuromuscular training as a portion of a knee and ACL injury prevention
interventions for decreasing ACL injury program is relatively strong. The systematic review
of the literature reported by Hewett et al. found that
Neuromuscular training appears to be effective
ff at reduced ACL injury risk occurred in those inter-
reducing knee injury risk, particularly for female ventions that included plyometrics as part of the
62 The Traumatic Knee

training program, while those that did not include Training programs that incorporate plyometrics
plyometrics did not reduce knee or ACL injury risk result in safe levels of varus or valgus stress about
(85,86). The focus of plyometrics should be on the knee, and may increase “muscle-dominant” neu-
proper landing, cutting, and jumping techniques romuscular control patterns and reduce “ligament-
and body mechanics during these movements. dominant” neuromuscular control patterns.
Studies by Hewett et al. (85,86), Myklebust et
al. (1) and Mandelbaum et al. (87) all incorpo-
rated high-intensity plyometric movements
into the design of their intervention programs
(Figs. 5–9). The studies by Heidt et al. (88) and
Soderman et al. (89), did not reduce ACL injury
risk. This can be explained, at least in part, by
the fact that the studies by Soderman et al. (89)

Fig. 5 – Athletic position: The athletic position is a functionally stable

position with the knees comfortably flexed, shoulders back, eyes up, feet
approximately shoulder-width apart, the body mass balanced over the balls Fig. 6 – Wall jump: The athlete stands erect with her arms semi-extended
of the feet. The knees should be over the balls of the feet and chest should overhead. This vertical jump requires minimal knee flexion. The gastrocne-
be over the knees. This is the athlete-ready position and is the starting and mius muscles should create the vertical height. The arms should extend fully
finishing position for most of the training exercises. During some of the at the top of the jump. Use this jump as a warm-up and coaching exercise as
exercises the finishing position is exaggerated with deeper knee flexion in this relatively low intensity movement can reveal abnormal knee motion in
order to emphasize the correction of certain biomechanical deficiencies. athletes with poor side-to-side knee control.

Fig. 7 – Tuck jump: The athlete starts in the athletic position with her feet shoulder-width apart. She initiates the jump with a slight crouch downward while
she extends her arms behind her. She then swings her arms forward as she simultaneously jumps straight up and pulls her knees up as high as possible. At the
highest point of the jump the athlete is in the air with her thighs parallel to the ground. When landing the athlete should immediately begin the next tuck jump.
Encourage the athlete to land softly, using a toe to mid-foot rocker landing. The athlete should not continue this jump if theyy cannot control the high landing force
or if they utilize a knock-knee landing.
Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 63

and Heidt et al. (88) had little chance of estab- the studies that did not incorporate high-inten-
lishing if their intervention could reduce the risk sity plyometrics did not report reductions in ACL
of injury because the sample size was likely too injury risk. Hence, the plyometric component of
small, and from this perspective, these should be a pre-season intervention program appears to
considered preliminary studies. With this caveat, reduce serious ligamentous injuries, specifi fically
the studies that incorporated high-intensity ply- ACL injuries.
ometrics reported reduced ACL injury risk, while Plyometrics may be used as combined analysis and
training tools, with verbal or visual feedback, for
control of body motion, both during deceleration
and acceleration, and knee loading, especially with
respect to the reduction of abduction (or “valgus”)
torque about the knee. For example, Hewett et al.
have shown that plyometric jumps force control of
knee abduction torque (Fig. 7) (86). Th
The other exer-
cises that were included in the interventions that
reported decreased ACL injury risk were lateral
jumps over barriers (this forces trainees to stabilize
their trunk in the coronal plane while moving both
lower extremities side to side), landing and balanc-
ing on compliant surfaces and perturbed single-leg
balancing, and hop and holds for extended periods
(Figs. 12 and 13).

Movement biomechanics, technique, and education

components: coronal plane is key
Fig. 8 – Broad jump and hold: The athlete prepares for this jump in the
athletic position with her arms extended behind her at the shoulder. She The evidence in support of including movement
begins by swinging her arms forward and jumping horizontally and verti- biomechanics; landing, cutting, and jumping tech-
cally at approximately a 45° angle to achieve maximum horizontal distance. nique; and education components of the effective
The athlete must stick the landing with her knees flexed to approximately interventions is also relatively strong. Olsen et al.
90° in an exaggerated athletic position. The athlete may not be able to stick
(90) have reported that in sports performed on
the landing during a maximum effort jump in the early phases. In this situ-
ation, have the athlete perform a submaximal broad jump in which she can court and turf surfaces, most ACL injuries occur
stick the landing with her toes straight ahead and no inward motion of her by non-contact mechanisms during landing and
knees. As her technique improves, encourage her to add distance to her lateral pivoting. Th
The biomechanics of these land-
jumps, but not at the expense of perfect technique. ing and cutting movements can be improved with

Fig. 9 – One hundred and eighty-degree jump: The starting position for this jump is standing erect with feet shoulder width apart. She initiates this two-footed
jump with a direct vertical motion combined with a 180° rotation in mid air, keeping her arms away from her sides to help maintain balance. When she lands she
immediately reverses this jump into the opposite direction. She repeats until perfect technique fails. The goal of this jump is to achieve maximum height with a
full 180° rotation. Encourage the athlete to maintain exact foot position on the floor, by jumping and landing in the same footprint.
64 The Traumatic Knee

neuromuscular training. Neuromuscular training programs. Of the non-effective

ff studies in our lit-
can increase coronal and sagittal plane control of erature review, none incorporated landing/cutting
the lower extremity. For example, during a squat technique, and while only the Wedderkopp study
jump (Fig. 10), a two-footed plyometric activity, (91) found a decrease in traumatic lower extremity
post-training results show that lower extremity injuries, none of these interventions reduced ACL
valgus alignment can be reduced at the knee and injury risk. Methods for altering biomechanical
hip. Conversely, during a single-leg task such as a technique include those of Hewett et al. (85,86),
hop and hold maneuver (Figs. 12–16), the most which utilized a trainer to provide feedback and
ficant changes may occur in the sagittal plane awareness to an athlete during training, and of
of the knee. Myklebust et al. (1), which utilized partner train-
There is strong evidence in support of landing, cut- ing to provide the critical feedback regarding lower
ting, and jumping technique training and its effect
ff extremity alignment, particularly valgus (inward)
on reducing ACL injury risk. Hewett et al. reported positioning of the knee.
that technique and phase-oriented training, that Johnson et al. (92) reported that education and
corrected jump and landing techniques in ath- public awareness of the high occurrence and
letes reduced ACL injuries in a female intervention mechanisms of ACL injury can decrease injuries
group compared to female controls and resulted in in alpine skiers by greater than 50%. A reduction
injury levels similar to a male control group (85). of ACL injuries in ski instructors was achieved by
Myklebust et al. reported that the incidence of ACL using “guided learning” techniques that educated
injury in elite handball was reduced with training skiers to avoid “high-risk” skiing positions, such
designed to improve awareness of lower extrem- as the skier positioned with a majority of the
ity alignment and knee control during cutting and weight on the downhill ski and their hips below
landing activities (1). The studies by Hewett et al. their knees. This approach is supported by Pra-
(85), Mandelbaum et al. (87), and Myklebust et al. pavessis et al. (93), who reported that verbal or
(1), which successfully reduced ACL injury risk, visual or biofeedback regarding technique may
all incorporated landing technique analysis and decrease reaction forces at the knee and reduce
feedback during training into their intervention ACL injuries.

Fig. 10 – Squat jump: The athlete begins in the athletic position with her feet flat on the mat pointing straight ahead. The athlete drops into deep knee, hip and
ankle flexion, touches the floor (or mat) as close to her heels as possible, then takes off into a maximum vertical jump. The athlete then jumps straight up verti-
cally and reaches as high as possible. On landing she immediately returns to starting position and repeats the initial jump. Repeat for the allotted time or until her
technique begins to deteriorate. Teach the athlete to jump straight up vertically, reaching as high overhead as possible. Encourage her to land in the same spot
on the floor, and maintain upright posture when regaining the deep squat position. Do not allow the athlete to bend forward at the waist to reach the floor. The
athlete should keep her eyes up, feet and knees pointed straight ahead, and have their arms to the outside of their legs.
Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 65

Fig. 11 – Broad jump to vertical jump: The athlete performs three succes- Fig. 12 – Hop and hold: The starting position for this jump is a semi-
sive broad jumps, and immediately progresses into a maximum effort verti- crouched position on a single leg. Her arms should be fully extended behind
cal jump. The three consecutive broad jumps should be performed as quickly her at the shoulder. She initiates the jump by swinging the arms forward
as possible and attain maximal horizontal distance. The third broad jump while simultaneously extending at the hip and knee. The jump should carry
should be used as a preparatory jump that will allow horizontal momentum the athlete up at an approximately 45° angle and attain maximum distance
to be quickly and effi
fficiently transferred into vertical power. Encourage the for a single-leg landing. Athletes are instructed to lands on the jumping
athlete to provide minimal braking on the third and final broad jump to leg with deep knee flexion (to 90°). The landing should be held for a mini-
ensure that maximum energy is transferred to the vertical jump. Coach the mum of three seconds. Coach this jump with care to protect the athlete from
athlete to go directly vertical on the fourth jump and not move horizontally. injury. Start her with a submaximal effort on the single leg broad jump so
Utilize full arm extension to achieve maximum vertical height. she can experience the level of diffi
fficulty. Continue to increase the distance
of the broad hop as the athlete improves her ability to stick and hold the
final landing. Have the athlete keep her visual focus away from her feet, to
help prevent too much forward lean at the waist.

Fig. 13 – X-hops: The athlete begins faces a quadrant pattern stands, on a

single limb with their support knee slightly bent. She hops diagonally, lands
in the opposite quadrant, maintains forward stance and holds the deep
knee flexion landing for three seconds. She then hops laterally into the side Fig. 14 – Single leg balance: The balance drills are performed on a balance
quadrant and again holds the landing. Next she hops diagonally backward device that provides an unstable surface. The athlete begins on the device
and holds the jump. Finally, she hops laterally into the initial quadrant and with a two-leg stance with feet shoulder width apart, in athletic position.
holds the landing. She repeats this pattern for the required number of sets. As the athlete improves the training drills can incorporate ball catches and
Encourage the athlete to maintain balance during each landing, keeping single leg balance drills. Encourage the athlete to maintain deep knee flex-
her eyes up and visual focus away from their feet. ion when performing all balance drills.
66 The Traumatic Knee

Fig. 15 – Bounding: The athlete begins this jump by bounding in place.

Once she attains proper rhythm and form encourage her to maintain the
vertical component of the bound while adding some horizontal distance
to each jump. The progression of jumps progresses the athlete across the
training area. When coaching this jump, encourage the athlete to maintain
maximum bounding height. Fig. 16 - Hop and hold.

Single-leg balancing component and ACL injury risk

Though single-leg balance training alone may not be
ffective for decreasing ACL injury rates in female
athletes, as the small studies that incorporated
single-leg balancing alone did not report decreased
A core component? Evidence for the effects
ff of “core
knee or ACL injury risk in female athletes, it may be stability” training
an important component of neuromuscular train- There is not clear evidence whether “core stabil-
ing designed to decrease non-contact knee and ACL ity” exercises should be incorporated into an
injury. The studies by Hewett et al. (85,86) and Man- intervention to reduce knee ligament injuries. It
delbaum et al. (87) incorporated single-leg stability is not clearly defi
fined what “core stability” exer-
training, primarily utilizing hold positions from a cises actually represent and what their effectsff
decelerated landing. Single-leg stability can be gained are on the muscles that stabilize the trunk, hip
with balance training on unstable surfaces. Mykle- and pelvis. However, Zazulak et al. (68,96) dem-
bust et al. (1) utilized partner training on Airex mats. onstrated that measures of “core” or trunk pro-
Again, however, the intervention programs that used prioception and displacement predicted risk of
balance training in isolation were not effectiveff in ACL injury in collegiate athletes with high sen-
reducing knee injuries in females. Wedderkopp et al. sitivity and specifi
ficity. Interestingly, this eff
(91) reported a reduction in all soccer-related injuries, was observed in female, but not male, collegiate
although not knee or ACL injuries. Soderman et al. athletes. This may indicate the need for including
(89) were not eff ffective in reducing injuries in female trunk perturbation and strengthening in optimal
soccer players. Wedderkopp et al. (91) and Soder- interventional training programs. The Th findings
man et al. (88) focused on balance training, primarily support the integration of proprioceptive stability
utilizing unstable wobble boards. Therefore,
Th balance training in ACL injury interventions, at least for
training alone may not be as eff ffective for ACL injury females. Krosshaug et al. (69) suggested that pre-
prevention as when it is combined with other types ventive programs to enhance knee control should
of training. Interestingly, Caraffa ff et al. (94) studied focus on avoiding valgus motion about this joint
male soccer players and showed a significantfi eff
ffect of and include distractions resembling those seen in
balance board exercises on reducing ACL injury and match situations.
reported that balance training may be more effec- ff
tive in males than females. Alternatively, Beynnon et
al. (95), in a prospective study, reported that female Strength training eff
ffects on knee injury risk
athletes who suffered
ff first-time ankle injuries had
greater body sway than female athletes who did not Resistance training alone has not been shown to
go on to injury, while male athletes who went on to reduce ACL injuries. However, inferential evidence
ankle injury did not demonstrate increased trunk suggests that resistance training may reduce injury
sway compared to uninjured males. based on benefi ficial adaptations that occur in
Clinical basis: epidemiology, risk factors, mechanisms of injury, and prevention of ligament injuries of the knee 67

bones, ligaments, and tendons after training. For ing sessions should be performed more than one
example, Lehnhard et al. (97) signifificantly reduced time per week, preferably at least two and up to
injury rates with a strength training regimen in five times per week. The total pre-season training
men’s soccer. The studies by Hewett et al. (85,86) duration of the intervention program should be
and Mandelbaum et al. (87) incorporated strength a minimum of 6, preferably 8 or more, weeks in
training in their intervention protocols. Myklebust length. Pfeiffer
ff et al. (83) reported that 20 min of
et al. (1), Heidt et al. (88), Soderman et al. (89), “in-season” exercise 2 days per week was not suf-
and Petersen et al. (98) did not include strength ficient to decrease ACL injury risk in high school
training in their interventions. The designs that age female basketball players. Gilchrist et al. (99)
incorporated strength training were among the also reported that an “in-season” program, with no
most effffective at decreasing ACL injury rates. But “pre-season” component, was only effective
ff in the
strength training in isolation may not be a prereq- last half of the season.
uisite for prevention, as the Myklebust et al. (1) The most effffective programs are progressive in nature.
study was eff ffective in reducing ACL injury risk, Exercises should progress to techniques that initiate
and it did not incorporate strength training. In the perturbations that force the athlete to decelerate and
final analysis, weight training alone has not been control the body in order to successfully perform the
reported to be eff ffective at decreasing ACL injury landing, cutting, and jumping techniques. Th The inter-
rates and may not need to be incorporated into a vention should preferably be phasic in nature. Three
successful intervention. It is important for us to exercise phases, such as technique, power, and per-
point out that this may apply only to those sub- formance phases, are often utilized to facilitate pro-
jects who have adequate strength prior to entering gressions designed to improve the athletes’ability to
an injury prevention program. control body motion during dynamic activities. All
exercises in each phase should be progressed to exer-
cise techniques that incorporate perturbations that
Targeting participation in ACL injury interventions force the athlete to decelerate and control the body
to individuals or teams in multiple planes of motion, particularly the coronal
plane, in order to successfully perform each technique
Athletes at the greatest risk of ACL injury should with optimal form and safety level.
participate in neuromuscular training interven-
tions to decrease the risk of injuring this important
ligament. This
Th approach is specifi fic to the individual Conclusions
athlete. The neuromuscular training protocol should
preferably be designed and instituted specifi fically for There is good evidence that neuromuscular train-
and with athletes selected for neuromuscular training ing decreases knee and ACL injury incidence in ath-
based on identified
fi neuromuscular defi ficiencies and letes. Plyometrics in combination with biomechan-
imbalances. The
Th authors realize that the individual- ics and technique (e.g., jumping/landing) training
ized approach may not be tenable for team athletes appear to induce neuromuscular changes that
and their coaches. Although we do not know if the reduce ACL injury risk. Increased lower extrem-
generalizations from our review of the literature dis- ity muscle recruitment and strength likely have a
cussed above apply to all athletes or just those who direct eff
ffect on the loading of the ACL during activ-
participate in jumping, landing, and cutting sports, ities that involve cutting and landing. Although
we can presume that there will be positive effectsff of ACL injuries likely occur too quickly (less than 70
neuromuscular training programs designed around ms) for refl
flexive muscular activation (greater than
these basic commonalities in effective
ff interventions. 100 ms), athletes can adopt preparatory muscle
These broad generalizations for the athlete in cutting recruitment and movement patterns that reduce
and landing sports, for “team training,” from the the incidence of injuries caused by unexpected
studies discussed above, should be eff ffective if plyo- perturbations. The studies discussed above pro-
metric training and landing, cutting, and jumping vide strong, but not unequivocal, evidence that
technique training are included in the intervention. neuromuscular intervention training and educa-
tion programs are likely to be an effective
ff solution
to the problem of gender inequity in ACL injury.
The proper “training dose”:
e how much and how often Selective combination of neuromuscular training
interventions should be performed components may provide additive effects, ff further
reducing the risk of ACL injuries.
Neuromuscular power can increase within 6 weeks It appears that plyometric power and biomechan-
of training and may result in decreases in peak ics technique training specifific to landing, cutting,
impact forces and knee abduction torques. Th The and jumping activities can induce neuromuscular
evidence from the literature indicates that train- changes and prevent ACL injury, at least in female
68 The Traumatic Knee

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75. Krosshaug T, et al. (2007) Biomechanical analysis of year follow up. Am J Sport Med 33(6)<AQ: Please provide
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ing the incidence of ACL injuries in female athletes: two- Society for Sports Medicine in San Francisco, CA
Chapter 7

H.G. Potter, D.B. Sneag,

L.R. Chong
MRI evaluation of knee ligaments

Introduction tion injuries associated with ligament instability.

Cartilage-sensitive imaging is essential in order

ue to its superior soft tissue contrast, mul- to detect chondral shearing injuries associated
tiplanar capabilities and lack of ionizing with ligament tears, which may alter both the
radiation, magnetic resonance (MR) imag- type of surgery performed as well as periopera-
ing (MRI) is a well-suited tool for evaluation of tive management.
knee ligaments. Strict attention to imaging tech- While standardized extremity coils are effective
nique is imperative, however, in order to provide in evaluation of the ligaments, phased array coils
accurate and reproducible assessment of ligament allow for increased signal to noise due to the pres-
integrity, as well as to detect associated complica- ence of more coil elements that act in concert to
tions, including meniscal and chondral injuries. increase the signal received from the excited nuclei
Following ligament reconstruction, modification
fi in the tissue studied. A recommended imaging pro-
of pulse sequence parameters is essential to pre- tocol for the assessment of knee ligaments is pro-
vent artifact from metallic fixation devices that vided in Table 1 (1.5 and 3 T).
would preclude an accurate assessment of recon-
struction integrity. While the capabilities of MRI Table 1 – Recommended protocol for MRI of the knee (1.5- and 3-T mag-
in assessing the static and dynamic stabilizers of nets).
the knee joint are well founded, it is important A. 1.5-T magnet
for the referring clinician to correlate MRI find-
fi Coil Phased array extremity knee coil
ings with the clinical assessment of functional
Position Feet first supine
ligament stability.
Landmark Patellar apex
Series I Coronal fast spin echo (cartilage sensitive)
TR 4000-4500/TE 34 ms (effective); VBW 32
Imaging technique kHz; ETL 8-12; FOV 11–13 cm; SL 3.0 mm no
gap; matrix 512 × 256–320; NEX 2; phase
Higher field strength MR units (1.5 or 3 T) gen- correct; NPW
erate increased signal to noise and permit higher Series II Sagittal fast spin echo with fat suppression
resolution imaging within acceptable scan times. TR 3500-4000/TE 40 ms (effective); VBW
Protocols should include coronal, sagittal, and 20.8 kHz; ETL 8-12; FOV 16 cm; SL 3.5–4 mm
axial images of the knee in order to fully evalu- with no gap; matrix 256 × 224; NEX 2; phase
ate the ligaments and surrounding structures, correct; NPW
and appropriate slice resolution of 3–4 mm with Series III Sagittal fast spin echo (cartilage sensitive)
no interslice gap is imperative, particularly in the TR 4000-4500/TE 34 ms (effective); VBW 32
coronal plane, to most eff ffectively evaluate the kHz; ETL 8-12; FOV 16 cm; SL 3.5 mm with no
posterolateral corner stabilizers. High in-plane gap; matrix 512 × 384; NEX 2; phase correct;
spatial resolution is important to depict the thin- NPW
ner but important structures of the posterolateral Series IV Axial fast spin echo (below patellar apex to
corner; this may be achieved by use of a higher base; cartilage sensitive)
imaging matrix of 512 × 320–512. Fast spin echo TR 4500/TE 34-40 ms (effective); VBW 32
techniques are eff ffective in evaluating meniscal kHz; ETL 10; FOV 14 cm; SL 3.5 mm with no
injuries (1) as well as the integrity of the articular gap; matrix 512 × 256–384; NEX 2; phase
cartilage (2,3). At least one plane obtained with correct; NPW
a fat suppression technique is also important in Series V Sagittal fast spin echo (meniscal windows)
order to “rescale” the contrast range and thereby TR 2300/TE 13 ms (effective); VBW 20.8; ETL
increase the conspicuity of translational or impac- 4-5; matrix 256 × 224; NEX 2
72 The Traumatic Knee

B. 3-T magnet (PCL) buckle (5) and “uncovering” of the posterior

Coil Phased array extremity knee coil horn of the lateral meniscus on sagittal images. In
Position Feet first supine addition, the ability to visualize the entire fi fibular
Landmark Patellar apex
(lateral) collateral ligament on one coronal image
should draw attention to the ACL, as it is typically
Series I Coronal fast spin echo (cartilage sensitive)
necessary to trace the former structure on multiple
TR 5100/TE 28 ms (effective); VBW 62.50 kHz;
coronal images in the setting of an intact ACL. Other
ETL 13; FOV 14 cm; SL 3.5 mm with no gap;
associated injuries in the setting of ACL may include
matrix 512 × 480; NEX 1; phase correct; NPW
O’Donoghue’s “unhappy triad,” which is described as
Series II Sagittal fast spin echo with fat suppression a medial collateral ligament (MCL) tear, an ACL tear,
TR 5000/TE 40 ms (effective); VBW 41.67 kHz;
and a medial meniscal tear (6). The Segond fracture
ETL 16; FOV 18 cm; SL 3.5 mm with no gap;
is an avulsion fracture of the lateral capsule from the
matrix 288 × 288; NEX 1; phase correct; NPW
tibia, which is noted as an often subtle, vertically ori-
Series III Sagittal fast spin echo (cartilage sensitive) ented cortical fragment on an anteroposterior (AP)
TR 5100/TE 28 ms (effective); VBW 62.50 kHz; radiograph, but more clearly delineated on MRI as a
ETL 13; FOV 16 cm; SL 3.5 mm with no gap; capsular avulsion on coronal images (Fig. 2) (7).
matrix 512 × 480; NEX 1; phase correct; NPW
Series IV Axial fast spin echo (below patellar apex to
base; cartilage sensitive)
TR 5300/TE 28 ms (effective); VBW 62.50 kHz;
ETL 17; FOV 14 cm; SL 3.5 mm with no gap;
matrix 512 × 480; NEX 1; phase correct; NPW
Series V Sagittal fast spin echo
TR 3200/TE 12 msec (effective); VBW 62.50
kHz; ETL 6; matrix 288 × 288; NEX 1
NPW, no phase wrap
VBW, variable bandwidth (reported over the entire frequency range);
ETL, echo train length;
SL,slice thickness;
NEX, number of excitations.

Cruciate ligaments
The anterior cruciate ligament (ACL) is composed of A
two main components: the anteromedial band and
the posterolateral bulk, the latter of which is the
primary stabilizer for preventing the pivot shift or
abnormal internal rotation of the tibia relative to the
femur. Increased signal intensity between these two
components may be encountered due to the signal
average of the adjacent intercondylar fat and should
not be misinterpreted as the presence of pathology.
Due to the inherent obliquity of the ACL fi
fibers, some
investigators have recommended oblique imaging
of the ACL, obtained from coronal or axial images
(4). This technique may be useful when imaging the
knee on low-fifield MRI systems (0.2–0.35 T), but this
is not part of standard practice and on higher field
strength systems, the ACL can be eff ffectively evalu-
ated with standardized imaging planes.
The greatest predictive value in detecting complete
tears of the ACL is the presence of a complete dis- B
continuity in the ligament, often associated with
Fig. 1 – Sagittal (A) fat-suppressed and cartilage sensitive (B) fast spin echo
a characteristic transchondral fracture or “bone MR images in a 42-year-old man following acute ACL tear demonstrate the
bruise” pattern (Fig. 1). Due to the anterior transla- typical pattern of bone marrow edema (arrows) and effect on overlying
tion of the tibia relative to the femur in the setting cartilage (arrowheads) due to the transchondral fracture associated with
of an ACL tear, important secondary signs may also a pivot shift, located above the anterior horn of the lateral meniscus in the
be noted, including a posterior cruciate ligament lateral femoral condyle and at the posterolateral tibia.
MRI evaluation of knee ligaments 73

Fig. 3 – Sagittal fast spin echo MR image in a 30-year-old man demon-
strates complete disruption of both fascicular attachments of the lateral
meniscus from the capsule (arrows).

Fig. 2 – Anteroposterior (A) radiograph and coronal (B) fast spin echo MR images
in a 15-year-old girl following acute ACL tear demonstrate a Segond fracture
(arrows), reflecting an avulsion of the tibial attachment of the lateral capsule.
Meniscal tears associated with ACL tears include
disruption of the fascicles (Fig. 3), peripheral, ver-
tically oriented tears of the posterior horn of the
medial meniscus, as well as a radial tear of the tib-
ial attachment of the posterior horn of the lateral
meniscus. The latter injury may be subtle on MRI,
yet be clinically relevant, and it is typically caused
by translation of the tibia anteriorly in the setting
of an ACL tear, where the posterior horn of the lat-
eral meniscus remains “tethered” posteriorly by the
meniscofemoral ligament attachments (Fig. 4) (8).
The “bone bruise” seen following ACL tears with
pivot shift is now recognized as a transchondral
fracture of varying severity. Bone marrow edema
pattern located above the anterior horn of the
lateral meniscus on sagittal images, as well as
over the far posterior margin of the lateral tibial B
plateau, is accompanied by a variety of chondral Fig. 4 – Sagittal fast spin echo MR images in a 15-year-old boy demon-
injuries ranging from compression to shear, the strate an acute ACL tear (A, arrow) and a radial tear of the tibial attachment
latter of which is more common over the convex of the posterior horn of the lateral meniscus (B, arrow).
74 The Traumatic Knee

surface of the tibial plateau and results in a more (12). Accuracy is slightly lower when partial tears
severe magnitude of initial chondral injury (9). are included, but it is still acceptable at 90–91%. Of
Tiderius et al. studied 24 patients for an average of note, similar accuracy has been reported at both
3 weeks following ACL tear with delayed gadolini- middle (0.5-T) and higher (1.5-tesla) field strengths
um-enhanced MRI and disclosed a generalized loss (12). In addition to high diagnostic accuracy, MRI
of glycosaminoglycan index from both the lateral can identify other injuries not easily assessed on
and medial femoral condylar cartilages, suggesting arthroscopy, particularly injuries to extracapsular
that the traumatic injury may affectff overall car- structures (13).
tilage homeostasis, rather than just the cartilage The diagnosis of partial ACL tears is made based on
under the bone bruise (10). partial discontinuity of the fibers. Careful scrutiny
While eminence avulsion at the ACL footprint is of the orientation of the individual components of
typically diagnosed on routine radiographs, con- the ACL is essential, where one may see preferen-
comitant MRI in this setting may be useful in dis- tial horizontal orientation of one component due
closing associated injury, as well as more accurately to partial ligament laxity (Fig. 6). Acute partial
assessing the degree of displacement (Fig. 5). ACL tears are typically associated with moderate
Clinical detection of ACL tears in acute rotational to large joint eff
ffusions. With chronicity, partial
injuries is diffi
fficult, and MRI may be useful in this ACL tears may remodel, and it may be challenging
setting (11). The accuracy of MRI in diagnosing to note the presence of a partial ligament injury
complete ACL tears compared to surgery as the gold with apparent tissue continuity on sagittal images.
standard is high, ranging between 95% and 96% Careful evaluation to detect evidence of prior tran-


Fig. 5 – Sagittal (A) and coronal (B) fast spin echo MR images in a 49-year- Fig. 6 – Sagittal fast spin echo MR images in a 54-year-old man with mod-
old woman demonstrate avulsion and displacement of the tibial eminence erate ACL laxity following prior partial ACL tear demonstrate preferential
at the ACL footprint (arrows). horizontal orientation of the posterolateral bulk fibers.
MRI evaluation of knee ligaments 75

schondral fracture may be helpful in disclosing a PCL tears are also noted by the presence of com-
previous high-grade ACL tear (Fig. 7). plete or partial discontinuity of the thick bun-
Chronic, complete ACL tears are typically associ- dles of the ligament. Caution should be utilized
ated with horizontal orientation of the hypoin- so as not to mistake the adjacent meniscofemo-
tense remnant, which often appears scarred to the ral ligaments of Humphrey or Wrisberg as par-
PCL (Fig. 8) or resorbed, leaving an empty, fat-filled
fi tial tears of the ligament or displaced meniscal
intercondylar notch (Fig. 9). fragments (Fig. 11). In the setting of a PCL tear,
Ganglion cyst formation of the cruciate ligaments these ligaments may remain stable and account
may be seen and refl flects mucinous degeneration for foci of hypointensity seen in cross section on
of connective tissue with or without synovial fluidfl MRI (Fig. 12).
imbibition (14). A clue to this diagnosis is the pres- Associated injuries of PCL tears include chondral
ence of intraosseous ganglion cysts, which often shearing injuries over the medial femoral condyle,
form on the roof of the intercondylar notch in the and careful follow-up of these lesions is important
distal femur, as well as in the central tibia (Fig. 10). in the setting of PCL insuffi
fficiency, as rapid degrada-
Large, soft tissue ganglia may cause intermittent tion of articular cartilage may be seen, particularly
pain or restricted knee motion (typically in full in the setting of a high-performance athlete, where
flexion), but do not necessarily refl
flect the presence high loads are imparted to the PCL-deficient
fi knee
of functional ACL instability or partial tear (14). (Fig. 13).

Fig. 8 – Sagittal fast spin echo MR image in a 31-year-old man demonstrates
a chronic ACL tear with horizontal orientation of the scarred remnant (arrow).

Fig. 7 – Sagittal fast spin echo MR images in a 43-year-old man with a his-
tory of prior knee injury demonstrate apparent continuity of the ACL fibers
(A, arrow) but evidence of a prior transchondral fracture (B, arrow), indicat- Fig. 9 – Coronal fast spin echo MR image in a 31-year-old man demonstrates an
ing the patient sustained a previous high grade ACL tear. empty intercondylar notch, indicating partial resorption of the ACL (arrow).
76 The Traumatic Knee

Fig. 10 – Sagittal (A) fat-suppressed and sagittal (B) fast spin echo MR images in a 48–year-old woman demonstrate an ACL ganglion extending posteriorly
(arrows). Note the incipient intraosseous ganglion formation in the anterior aspect of the tibia (arrowhead).


Fig. 11 – Coronal (A) and sagittal (B) fast spin echo MR images in a 67-year-old woman demonstrate an intact meniscofemoral ligament of Humphrey
(arrows). Coronal (C) and sagittal (D) fast spin echo MR images in a 42-year-old man demonstrate an intact meniscofemoral ligament of Wrisberg (arrows).
MRI evaluation of knee ligaments 77

Fig. 12 – Sagittal fat-suppressed

(A) and fast spin echo (B) MR images
in a 27-year-old man following a
basketball injury that occurred 1½
weeks previously demonstrate a
high-grade partial PCL tear with an
intact meniscofemoral ligament of
Humphrey (arrows).

Fig. 13 – Sagittal (A, B) and coronal (C) fast spin echo MR

images in a 26-year-old football player following a hyper-
extension injury 1 month previously reveal a complete
mid-substance PCL tear (A, arrow) and chondral shear
over the medial femoral condyle (B and C, arrows). Sagit-
tal (D, E) fast spin echo MR images in the same patient 9
months following the injury reveal remodeling of the PCL
(D, arrow) and progressive cartilage loss over the medial
femoral condyle (E, arrow).


78 The Traumatic Knee

Medial collateral ligament

Medial collateral ligaments have distinct deep
and superfificial components, separated by a tibial
collateral bursa. Injuries to the MCL are more
common on the femoral side. In a pure valgus
load, tears of the MCL may be associated with
compression of the lateral femorotibial compart-
ment with bone marrow edema pattern or true
osteochondral fractures. Avulsion of the deep
fibers from the medial femoral condyle may also
be associated with a focal edema pattern in the
central aspect of the medial femoral condyle, as
well as extracapsular soft tissue edema (Fig. 14).

Fig. 15 – Axial fast spin echo MR image in a 17-year-old adolescent follow-

ing a recent flexion valgus injury demonstrates complete disruption of the
medial patellofemoral ligament and retinaculum (arrow).

If a tear of the MCL is isolated to the far anterior

fibers on coronal images, careful scrutiny of the
axial images should be performed, as the medial
patellofemoral ligament and retinaculum may
tear as an anterior extension of a primary val-
gus injury, particularly in knee flexion (Fig. 15).
Tears of the PCL often may be associated with a
reactive pes anserine bursa or injury to the semi-
membranosus attachment, particularly in the
setting of a higher force velocity injury, which
A may also result in concomitant cruciate ligament
tear (Fig. 16). It is important to remember that
the assessment of MCL tears on MRI refl flects the
anatomic discontinuity of the fibers
fi but does not
necessarily correlate to the degree of functional
valgus instability, as assessed by clinical exami-
nation (15).

Posterolateral corner injuries

The posterolateral corner is a collection of soft
tissue constraints that act to stabilize against
varus stress and excessive external rotation of
the tibia relative to the femur. The structures
include the fibular (lateral) collateral ligament,
popliteus tendon, popliteofibular ligament, arc-
uate ligament, and the fabellofibular ligament
(Fig. 17). Failure to recognize posterolateral
B corner injury is clinically relevant with regards
to rotational instability, which may compro-
Fig. 14 – Sagittal (A) fat-suppressed MR image in a 23-year-old woman
1 month following a motor vehicle accident reveals a focal edema pattern mise the functional integrity of subsequent ACL
in the medial femoral condyle. Coronal (B) fast spin echo MR image in the reconstruction (16).
same patient reveals an avulsion injury of the medial collateral ligament Evaluation of the posterolateral corner struc-
(arrow). tures is best made on a combination of several
MRI evaluation of knee ligaments 79

Fig. 17 – Coronal fast spin echo MR image in a 38-year-old woman dem-
onstrates an intact lateral collateral ligament (arrowheads) and intact
popliteus tendon at the hiatus (arrow).

Fig. 16 – Sagittal (A) fat-suppressed MR image in a 19-year-old man
following a football injury that resulted in a complete PCL tear dem-
onstrates avulsion of the semimembranous tendon from its attach-
ment onto the femur with disruption of the posteromedial capsule.
Axial (B) fast spin echo MR image confirms the tendon detachment Fig. 18 – Coronal fast spin echo MR image in a 38-year-old woman
(arrow). demonstrates an intact popliteofibular ligament (arrow).

planes of imaging, but the bulk is best visualized uncommonly torn during muscle tendon injury
on coronal images, requiring both high in-plane of the popliteus (19).
and through-plane (slice) resolution. As a rota- In the setting of a chronic injury, the fifibular col-
tory stabilizer, the popliteus tendon should be lateral ligament may remodel with resultant thick-
carefully traced on consecutive coronal images ening. Proximal injury to the popliteus is not
from the muscle tendon junction to the femo- uncommon, and careful evaluation of the coronal
ral attachment. The popliteofibular ligament is and axial images is necessary in order to detect a
seen as a hypointense, obliquely oriented struc- chronic proximal detachment, where the tendon
ture coursing from the popliteus tendon, often often appears scarred in the lateral gutter (Fig. 19).
on posterior coronal images at the level of the Proximal fibular avulsion fractures may very likely
muscle tendon junction, down to the fibular destabilize not only the conjoined tendon of the
head (Fig. 18). While subtle in its anatomic pro- biceps femoris muscle but also the fi fibular collat-
portions on MRI, this is an important stabilizer eral ligament and the popliteofi fibular ligament
of the posterolateral corner (17,18). It is not (Fig. 20).
80 The Traumatic Knee


Fig. 19 – Sagittal (A) and axial (B) fast spin echo MR images in a 65-year- Fig. 20 – Coronal (A) fast spin echo and sagittal (B) inversion recovery MR
old man demonstrate chronic proximal popliteus injury with formation of images in a 22-year-old professional football player show a small avulsion
intraosseous ganglion cysts (arrows). fracture (arrows) from the tip of the fibular head, at the insertion of the
biceps femoris tendon, and the popliteofibular ligament, compatible with a
posterolateral corner injury.

Multiple-ligament-injured knee injury ranges between 4.8% in low-velocity inju-

ries (20) and 45% in high-velocity injuries (21).
Knee dislocation is a serious injury that results As a delay may exist between intimal injury
in disruption of many of the primary and sec- and clinical evidence of arterial insufficiency, a
ondary stabilizers of the joint, often accompa- negative initial examination with intact distal
nied by meniscal and cartilaginous disruption. pulses does not preclude a clinically relevant
Careful review of all planes of imaging is nec- arterial compromise. Conventional arteriog-
essary to detect the magnitude of osseous and raphy via direct arterial puncture carries an
soft tissue injury; this is essential in aiding sur- attendant morbidity of arterial injury, the use
gical planning and graft requirements for subse- of ionizing radiation, and the risks of iodinated
quent ligament reconstruction, meniscal repair, contrast agents. Contrast-enhanced MR angiog-
and cartilage restoration procedures. In addi- raphy performed via an intravenous injection is
tion, injuries may further involve neurovascular an effective means by which to assess regional
structures; the reported incidence of vascular vascular integrity, and requires an additional
MRI evaluation of knee ligaments 81

ability to perform frequency-selective fat sup-

pression may also be hampered; as such, a fast
inversion recovery or STIR (short tau inversion
recovery) sequence is recommended. Fast spin
echo techniques are very effi
fficacious in assessing
the integrity of soft tissue structures surround-
ing instrumentation.
The normal signal properties of ligament recon-
struction are those of a homogeneously hypoin-
tense signal intensity on moderate to long echo
time pulse sequences. Within the first 6 months
following knee construction, however, the graft
may show variable signal hyperintensity, par-
ticularly on a short echo time pulse sequence.
This has been attributed to periligamentous
vascularity and/or impingement (23), as well
as the process of “ligamentization” of the ten-
don graft (24,25). It is important to recall that
there is a slower rate of biologic incorporation
Fig. 21 – Axial fast spin echo MR image in a 35-year-old man who sus- of allograft versus autograft tissue, particularly
tained a multiple ligament knee injury demonstrates partial disruption of in the first 6 months, which may account for
fascicles of the common peroneal nerve (arrow). (Reprinted with permis- signal inhomogeneity encountered on MR pulse
sion from Potter et al. (22).) sequencing. The mode of biologic fixation may
also affect the signal properties of the graft, as
bioabsorbable constructs may not only lead to
3–5 min of scanner time. MR angiography may inhomogeneity in the intra-articular portion
easily be performed at the end of the standard of the graft but may also account for a regional
examination to assess the ligaments and has adverse synovial reaction that might simulate
proven efficacious in detecting clinically occult that of infection. Osteolysis may occur follow-
vascular injury (22). ing bioabsorbable fixation, which may create
Regional nerves may also be subject to injury, considerable increased signal intensity sur-
with the common peroneal nerve sustaining the rounding the soft tissue within the osseous
highest incidence of injury, likely due to its close tunnels.
approximation to the structures of the poste- Assessment of graft position is essential, as
rolateral corner. While complete nerve transec- malposition is included in the most common
tion is relatively uncommon, stretching injuries causes of graft failure. The orientation of the
may cause partial fascicle disruption resulting ACL reconstruction on sagittal images should be
in a foot drop. The nerve may also be encased parallel to the roof of the intercondylar notch,
in hematoma, particularly in the setting of with good bone ingrowth into both the femoral
associated fractures. Nerve architecture is best and tibial tunnels (Fig. 22). If there is excessive
assessed on consecutive axial images, where anterior placement of the femoral tunnel, the
focal alteration of fascicles and increased intra- graft may impinge on the roof of the intercondy-
neural signal should raise strong suspicion for lar notch, forming the so-called “cyclops” lesion,
injury (Fig. 21). indicative of focal hypertrophy of the synovium
due to abutment of the graft against the notch.
Similar findings may be seen following failure to
fully debride the native ACL stump at the time
Imaging of the reconstructed ligaments of reconstruction (Fig. 23). Focal graft impinge-
ment against the roof of the intercondylar notch
Following ligament reconstruction, it is necessary should be distinguished from global arthrofibro-
to modify pulse sequence parameters to reduce sis, which is a cytokine-mediated, globalized cap-
artifact generated by fi
fixation devices. In the pres- sular contracture (26). Failure of fixation at the
ence of metallic instrumentation, susceptibility bone graft or screw level is typically apparent on
artifact may be generated, creating large areas of radiographs; however, complications involving
signal distortion adjacent to the reconstructed plastic or biodegradable screws are best evalu-
ligament. Gradient echo techniques should be ated on MRI (Fig. 24).
avoided, as these are very susceptible to the arti- In the setting of an infection, inflammatory
fact induced by metallic instrumentation. The Th synovitis, as well as the presence of bone mar-
82 The Traumatic Knee


Fig. 22 – Sagittal fast spin echo MR images in a 28-year-old man demon- Fig. 23 – Sagittal (A) and axial (B) fast spin echo MR images in a 39-year-
strate an intact, properly positioned ACL graft (arrows) using autologous old man demonstrate anterior position of the ACL graft at the entrance of the
patellar tendon performed with an endoscopic technique. femoral tunnel with a cyclops lesion (arrows) due to graft impingement.

row edema extending into the tibial tunnel, is Conclusion

noted, particularly in the initial perioperative
setting before bone graft incorporation into Magnetic resonance imaging is an accurate, non-
the tunnels. The presence of pre-contrast bone invasive modality in the diagnosis of both acute
marrow edema followed by post-contrast mar- and chronic ligament injuries of the knee, helping
row enhancement is strongly suggested with to guide surgical planning and thereafter in the
the presence of concomitant osteomyelitis, assessment of the postoperative knee. Knowledge
particularly in the setting of tunnel widening of MR anatomy and imaging techniques, com-
and overt bone destruction (Fig. 25). Caution bined with an understanding of injury mecha-
should be utilized; however, to recall that in the nism and expected postoperative changes, allows
setting of bioabsorbable fixation, an inflamma- the clinician to correlate clinical assessment with
tory synovitis may ensue that is not infectious corresponding MRI findings to ensure a compre-
in etiology. hensive, accurate evaluation.
MRI evaluation of knee ligaments 83


Fig. 24 – Sagittal (A, B) and axial (C) fast spin echo MR images in a 45-year-
old man 6 months following bone-tendon-bone ACL reconstruction with
loss of terminal extension. While the sagittal images demonstrate anterior
placement of the femoral tunnel (A, arrow) and suspected cyclops lesion, a
displaced plastic screw (B and C, arrowheads) is noted against the anterior
synovial reflection.

Fig. 25 – Sagittal (A) fast spin echo MR image in a 67-year-old woman following ACL reconstruction demonstrates widening of the tibial tunnel (arrow)
and synovitis. The sagittal (B) fat-suppressed image shows corresponding enhancement following gadolinium administration (arrowheads), indicative of
septic arthritis with concomitant tibial osteomyelitis.
84 The Traumatic Knee

References accuracy of middle- and high-fi field-strength MR imaging

at 1.5 and 0.5 T. Radiology 197(3):826–830
1. Escobedo EM, Hunter JC, Zink-Brody GC, et al. (1996) 13. Munshi M, Davidson M, MacDonald PB, et al. (2000) The Th
Usefulness of turbo spin-echo MR imaging in the evalu- effi
fficacy of magnetic resonance imaging in acute knee inju-
ation of meniscal tears: comparison with a conventional ries. Clin J Sport Med 10(1):34–39
spin-echo sequence. AJR Am J Roentgenol 167(5):1223– 14. Deutsch A, Veltri DM, Altchek DW, et al. (1994) Symptom-
1227 atic intraarticular ganglia of the cruciate ligaments of the
2. Bredella MA, Tirman PF, Peterfy CG, et al. (1999) Accuracy knee. Arthroscopy 10(2):219–223
of T2-weighted fast spin-echo MR imaging with fat satura- 15. Schweitzer ME, Tran D, Deely DM, et al. (1995) Medial col-
tion in detecting cartilage defects in the knee: comparison lateral ligament injuries: evaluation of multiple signs, prev-
with arthroscopy in 130 patients. AJR Am J Roentgenol alence and location of associated bone bruises, and assess-
172(4):1073-1080 ment with MR imaging. Radiology 194(3):825–829
3. Potter HG, Linklater JM, Allen AA, et al. (1998) Magnetic 16. O’Brien SJ, Warren RF, Pavlov H, et al. (1991) Recon-
resonance imaging of articular cartilage in the knee. An struction of the chronically insufficient
ffi anterior cruciate
evaluation with use of fast-spin-echo imaging. J Bone ligament with the central third of the patellar ligament. J
Joint Surg Am 80(9):1276–1284 Bone Joint Surg Am 73(2):278–286
4. Hong SH, Choi JY, Lee GK, et al. (2003) Grading of ante- 17. Maynard MJ, Deng X, Wickiewicz TL, et al. (1996) The Th
rior cruciate ligament injury: diagnostic effi
fficacy of oblique popliteofifibular ligament. Rediscovery of a key element in
coronal magnetic resonance imaging of the knee. JCAT posterolateral stability. Am J Sports Med 24(3):311–316
27(5):814–819 18. Veltri DM, Deng XH, Torzilli PA, et al. (1996) The
Th role of the
5. Gentili A, Seeger LL, Yao L, et al. (1994) Anterior cruci- popliteofifibular ligament in stability of the human knee. A
ate ligament tear: indirect signs at MR imaging. Radiology biomechanical study. Am J Sports Med 24(1):19–27
193(3):835–840 19. Potter HG (2000) Imaging of the multiple ligament
6. O’Donoghue DH (1964) The unhappy triad: etiology, diag- injured knee. In: Johnson DL. Clin Sports Med. WB Saun-
nosis and treatment. Am J Orthop 6:242–247 ders 19(3):425–441
7. Goldman AB, Pavlov H, Rubenstein D (1988) The Segond 20. Shelbourne KD, Porter DA, Clingman JA, et al. (1991) Low-
fracture of the proximal tibia: a small avulsion that velocity knee dislocation. Orthop Rev 20(11):995–1004
flects major ligamentous damage. AJR Am J Roentgenol 21. Green NE, Allen BL (1977) Vascular injuries associ-
151(6):1163–1167 ated with dislocation of the knee. J Bone Joint Surg Am
8. Brody JM, Lin HM, Hulstyn MJ, et al. (2006) Lateral 59(2):236–239
meniscus root tear and meniscus extrusion with anterior 22. Potter HG, Weinstein M, Allen AA, et al. (2002) Magnetic
cruciate ligament tear. Radiology 239(3):805-810 resonance imaging of the multiple ligament injured knee.
9. Potter HG, Foo LF (2006) Magnetic resonance imaging of J Orthop Trauma 16(5):330–339
articular cartilage: trauma, degeneration and repair. Am J 23. Howell SM, Knox KE, Farley TE, et al. (1995) Revascular-
Sports Med 34(4):661–677 ization of a human anterior cruciate ligament graft dur-
10. Tiderius CJ, Olsson LE, Nyquist F, et al. (2005) Cartilage ing the first two years of implantation. Am J Sports Med
glycosaminoglycan loss in the acute phase after an anterior 23(1):42–49
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magnetic resonance imaging of cartilage and synovial poration of allograft anterior cruciate ligament replace-
fluid analysis. Arthritis Rheum 52(1):120–127 ments. Clin Orthop Relat Res 324:126–133
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Chapter 8

S.R. Piedade, E. Servien,

F. Lavoie, P. Neyret
Classification of knee laxities

Introduction plastic deformation. This

Th mechanical behavior is a
characteristic of the viscoelastic materials that is
described as time and history dependence (Fig. 1)
Ligament biomechanical behavior and function (1,2). However, if ligament elongation exceeds the
physiological limit (yield point), a plastic deforma-

nee joint stability is determined by the tion occurs. In that context, knee joint kinemat-
ligament and capsular complex combined ics is compromised, potentially leading to clinical
with intact osteocartilaginous structures. knee joint instability.
The ligaments are described as dense connective In this chapter, we discuss the diff fferent types of
collagenous tissue bands that connect one bone ligament injury and classifi
fication of knee ligament
to another. Their purpose is to support loads of instabilities.
tension, particularly on their long axis, allow-
ing joint stability and guiding knee joint move-
In the physiologic limit, ligaments and joint cap- Types of ligament injuries (terminology)
sule can lengthen without arriving at irreversible Sprain is defifined by an injury of ligament that
stretches or tears ligamentous fi
fibers without com-
plete ligament rupture. It is classified
fi in three dif-
ferent levels (Table 1) (3).

First-degree sprain
Clinically, it presents a localized tenderness and it
is followed by no instability. It is characterized as a
tear of a minimum number of ligament fi fibers.

Second-degree sprain
Clinical examination shows a slight-to-moderate
abnormal motion. It happens as a result of a larger
number of ligament fibers
fi ruptured when com-
Fig. 1 – Ligament mechanical behavior submitted a uniaxial tensile test. pared to level I.

Table 1 – Correlation of sprain level with ligament fibers tear and clinical instability.
Sprain Tears of ligament fibers (amount) Clinical instability
First-degree Minimum No
Second-degree More ligamentous fibers Abnormal motion (slight-to-moderate)
Complete ligament tear (rupture) Demonstrable instability
Clinical examination (joint surfaces opening)
Grade I Less than 0.5 cm
Grade II 0.5–1.0 cm
Grade III More than 1.0 cm
86 The Traumatic Knee

Third-degree sprain ACL integrity assessment tests

This level of injury is subdivided in three types, Lachman-Trillat test
according to joint surface opening: The examined knee is positioned at 20° of flexion,
1. Grade I = less than 0.5cm; and an anterior drawer is applied to the proximal
2. Grade II = 0.5 to 1.0cm; calf. Clinically, this test can be graded as a fi
firm or
3. Grade III= opening superior to 1.0 cm (complete soft endpoint (8).
ligament rupture and obvious clinical laxity).
Table 1 summarizes the sprain classification
fi lev- Anterior drawer test
els and correlation with ligament fibers
fi tear and
clinical instability. In this clinical test, the hip is flexed
fl to 45°, with
Laxity is defifined as looseness of a joint. It can be the knee flexed to 80–90°. The examiner places
reported as normal (patient’s collagenous char- his hands about the upper part of tibia and per-
acteristic) or abnormal and can be measured by forms anterior tibial displacement with the foot
radiological methods. in neutral, external, and medial rotations. Before
Instability is the result of ligament defi ficiency or performing the test, it is important to check if
absence. It is secondary to a traumatic injury. Clin- the hamstrings are relaxed to avoid false negative
ically, it leads to increased or excessive displace- test. It must be underscored that positive anterior
ment between tibial and femoral surfaces. drawer test is absent in isolated anterior cruciate
ligament (ACL) lesion.
These two maneuvers (Lachman-Trillat and ante-
rior drawer tests) allow the examiner to analyze
the anterior tibial displacement and assess the
Clinical examination (ligament tests) endpoint stiffness.
ff Anterior drawer test with inter-
During physical examination, the patient must be nal and external rotations will assess medial and
relaxed, and clinical laxity tests must be performed lateral corners.
gently. All tests are performed with the patient in
dorsal decubitus unless specified fi otherwise. The Pivot shift test
normal knee is examined first to establish the It reproduces the anterior tibial subluxation and
patient’s normal laxity: this provides the exam- reduction, during the flexion-extension
fl of the
iner with a baseline to determine pathologic lax- knee from 10° to 40°. A positive test confirms
fi an
ity (4–7). ACL disruption (9–11).

Medial and lateral compartment integrity PCL integrity assessment tests

assessment tests
Posterior drawer test
Valgus stress test With the knee flexed to 90°, the examiner first
The knee is flexed at 30° and a gentle valgus stress is observes the relationship between the tibia and
applied, with one hand placed on the lateral aspect femoral condyles. Normally, in the resting posi-
of the knee joint and the other hand grasping the tion the medial tibial plateau lies 1 cm anterior to
heel. This test evaluates the medial compartment the medial femoral condyle. It is considered the
of the knee joint. However, when performed with most accurate clinical test to determine PCL insuf-
the knee fully extended, it is helpful to check the ficiency. Rubenstein et al. (12) have shown that
posterior cruciate ligament (PCL) and posterome- the posterior drawer test is the most sensitive test
dial compartment’s status. (90%) and is highly specifi
fic (99%).Considering the
amount of subluxation, it is graded as I (1–5 mm),
Varus stress test II (5–10 mm), and III (more than 10 mm). Poste-
rior drawer test with internal and external rota-
Similarly, this test is performed with the knee
tions will assess medial and lateral corners.
flexed at 30°; however, a varus stress is applied to
the knee joint. It helps the physician to evaluate
the ligament restrictors of the lateral compartment Reverse pivot shift
of the knee. If this maneuver is performed with the This clinical test helps the clinician to discern combi-
knee in full extension, the PCL and posterolateral nation injuries from isolated PCL injuries. With the
ligament restrictors’ status are checked. It must patient in supine position, the examiner stands on
be kept in mind that both knees are evaluated and the side of the injured leg. One hand grasps the heel,
clinical findings compared. with the knee in full extension and neutral rotation.
Classification of knee laxities 87

Thereafter, a valgus stress is applied and the knee is rior laxity; however, a delayed stop is found in the
flexed. The test is considered positive when this test Lachman-Trillat test, and the pivot shift test is
induces a posterior subluxation of the lateral tibial negative. It must be emphasized that it can become
plateau between 20° and 30° of knee fl flexion and it a complete anterior laxity if patients return to the
remains in this position with more flexion.
fl It evalu- same level of sports activity.
ates instability related to the posterolateral com-
partment of the knee (arcuate ligament complex: Anterior medial laxity or advanced anterior laxity
arcuate ligament, lateral collateral ligament (LCL), Compared to the isolated laxity, anterior medial
popliteus muscle, and the lateral head of gastrocne- laxity shows a markedly positive anterior trans-
mius muscle). A posterior subluxation of the lateral lation graded as 6–10 mm. It is associated with
plateau reveals posterolateral instability; however, medial meniscal, capsular, and ligamentous inju-
the physical examination of both knees must be ries. It must be underscored that these peripheral
compared to avoid false positive test (13). injuries are secondarily produced by repeated acci-
dents in the 2 or 5 years following ACL disruption.
Other tests
Anterior posterolateral laxity
Other tests include recurvatum test and external This type of laxity is secondary to ACL disruption
rotation test (Dial test) (assess to posterolateral associated with injury of the posterior lateral com-
corner) (6). plex. Clinically, it is presented as a simple lateral
laxity as well, a recurvatum test as described by
Hughston, and frequently, the radiographic evalu-
Classifification systems of knee ligament instability ation shows an asymmetric lateral opening, par-
ticularly if there is a bilateral varus knee. However,
Lyon school classification anterior tibial translation is not marked.
Henry Dejour reported the laxity resulting from
chronic ACL defificiency in the following manner Anterior laxity associated with pre-arthritis
(Table 2) (12). This advanced stage of instability is the result of
5–10 years of evolution. It can also be the conse-
Anterior laxity quence of a limited surgical procedure such as a
Complete and isolated anterior laxity total menisectomy. Lateral radiographs show a
Lachman-Trillat and pivot shift tests are frankly minimum anterior tibial translation of 10 mm
positive, and there is a differential
ff anterior tibial associated to a medial or lateral knee pre-arthritis.
translation of 2–4 mm with the normal knee. Car-
Anterior lateral laxity associated with arthritis
tilage and menisci are normal.
In this stage, the arthritis is well established.
Partial and isolated anterior laxity Twenty to 30 years of ACL defi
ficiency is identifi
Initially, it can result from a partial rupture of the in these cases. Lachman-Trillat and pivot shift
ACL, but we think that more frequently it results tests are markedly positive. Lateral radiographs
from the healing of some fi fibers of the ACL over the allow the diagnosis, showing the medial condyle
PCL as described by Trillat. It may sometimes be embedded in the posterior medial tibial cupula.
the rupture of one bundle, more often the antero-
medial bundle. Clinically, this type of laxity is well Posterior laxity
tolerated by the patients, and frequently, there is Posterior laxity is the result of PCL injury, either
no knee instability. It presents the same anterior isolated or associated to peripheral ligament injury.
tibial translation as in complete and isolated ante- It can be subclassifi
fied as follows (14).

Table 2 – Dejour’s classification of triad.

Posterior Special
Medial Lateral Pivot Anterior
Hemarhrosis Recurvatum Lachman drawer tests and
laxity laxity shift drawer test
test lesions
Anteromedial + + 0 0 + + + 0
Anterolateral Hughston
triad + 0 + + + + 0 ±
Posteromedial A delayed
+ + to 0° 0 0 0 0 ±
Posterior stop
triad Posterolateral A delayed
+ 0 + ± 0 0 +
88 The Traumatic Knee

Pure or isolated posterior laxity Isolated lateral rotatory laxity

As its name implies, pure posterior laxity is pro- Isolated lateral rotatory laxity is seldom encoun-
duced by an isolated PCL injury. Clinically, the pos- tered as it results from an isolated injury of the
terior drawer test is less pronounced in internal as LCL, which is usually associated to an injury of the
compared to neutral and external rotations. posterior lateral corner.

Posterior medial laxity

Posterior medial laxity is considered a rare type Hughston’s classification
of posterior laxity. It is the consequence of injury
to the PCL and medial capsular and ligamentous In 1976, Hughston and colleagues and the Amer-
structures. Clinically, it presents as a valgus laxity, ican Orthopedic Society of Sports Medicine
in 30° of flexion as well as in full extension. The Research and Education Committee developed a
posterior drawer test is positive with the foot neu- classifi
fication based on rotation of the knee about
trally aligned as well as in internal rotation; how- the central axis of the PCL. The instabilities are
ever, the posterior drawer test in external rotation classifi
fied as straight or non-rotatory, and simple
remains normal. or complex rotatory instability (Table 3) (6,15,16).
Posterior lateral laxity Rotational instability
Posterior lateral laxity is the result of a com-
bined injury to the PCL and the posterior lateral It is defi
fined as instability where the rotation of the
corner of the knee joint. Clinical features are a knee is controlled by an intact PCL. Clinically, this
minimum of 10 mm of posterior tibial transla- type of knee ligament instability is subclassified
fi as
tion, an augmented varus laxity in 30° of flexion anterolateral, anteromedial, posterolateral, pos-
and in full extension, as well as an augmented teromedial, and combined.
recurvatum and a positive tibial external rota- Anterolateral rotatory instability
tion test (6). This instability is produced by an ACL rupture
associated to injuries to the lateral capsular liga-
Isolated peripheral laxity ment and the arcuate complex. Sometimes, the ili-
External rotatory laxity otibial band may be damaged, most commonly its
This exceptional type of laxity is produced by deep fibers. Clinically, it presents as an excessive
an isolated injury to the posterolateral corner internal tibial rotation and anterior subluxation of
of the knee joint. Physical examination shows the lateral tibial plateau. Positive clinical tests are
an augmented varus laxity at 30° of knee flex- the Lachman-Trillat test, pivot shift test, anterior
ion, a hyper mobility of the lateral femoro-tibial drawer test, and varus test at 30° of flexion.
compartment, a positive recurvatum-external
rotation test, a reverse pivot shift test, and an Anteromedial rotatory instability
increase of the tibial external rotation in flexion This instability results from a disruption of medial
at 90°. capsular ligament, medial collateral ligament, pos-
terior oblique ligament, and ACL. Sometimes, a
Isolated medial rotatory laxity medial meniscus tear can be associated. Physical
This laxity results from an isolated injury of the examination shows a marked external rotation of
posteromedial corner. Clinically, it displays a val- the tibia and anterior tibial displacement produced
gus laxity at 30° of knee flexion;
fl however, there is by anteromedial subluxation of the medial tibial
no valgus laxity with the knee in extension. plateau on the medial femoral condyle. A positive

Table 3 – Hughston’s classification and related ligament injuries.

Type of instability Lesion
Medial Medial compartment + LCP
Lateral Lateral compartment + LCP
Posterior LCP + post obl lig + arcuate lig
Anterior AM and AL capsule ± LCA
Anteromedial Medial compartment ± LCA
Combined simple Anterolateral 1/3 ant lateral capsule ± LCA
Posterolateral 1/3 post lateral capsule
Anterolateral + posterolateral All lateral compartment
Combined rotational
Anterolateral + anteromedial 1/3 third med compartment + lat
Classification of knee laxities 89

valgus stress test at 30° of knee fl

flexion, a positive Straight lateral instability
anterior drawer test, and a positive Lachman-Tril- This instability is produced by a tear of lateral sup-
lat test confi
firm the diagnosis. porting structures (lateral capsular ligament, LCL,
arcuate complex) and the PCL. Th The axis of tibial
Posterolateral rotatory instability rotation is consequently shifted toward the MCL.
This instability characterizes the injuries of the Clinical examination shows a lateral opening dur-
posterolateral corner (arcuate ligament, LCL, ing the adduction stress test performed at 0° and
popliteus tendon). It is sometimes associated to an 30° of knee flexion. The degree of lateral open-
injury of the biceps tendon. Clinically, the patient ing is directly related to the level of injury to the
may present a lateral thrust during his gait, result- iliotibial band. Th
The clinical examination shows a
ing from lateral tibial plateau rotation on the lat- positive posterior drawer test in neutral rotation
eral femoral condyle and posterolateral ligament and an increased translation with the knee rotated
ficiency. Positive external rotation recurvatum externally.
and posterolateral drawer tests are also observed.
The levels of injury of the LCL and iliotibial band Straight medial instability
are directly related to the magnitude of varus This instability is caused by a disruption of medial
stress test performed at 30° knee flflexion. Anterior supporting structures (MCL, middle third of the
and posterior drawer tests, Lachman-Trillat test, capsular ligament, and the posterior oblique liga-
and pivot shift test are all negative. ment). The
Th axis of tibial rotation is shifted toward
the LCL. Clinically, the abduction stress test at 30°
Posteromedial rotational instability and 0° shows a medial space joint opening. If the
The disruptions of posteromedial corner (medial ACL is torn, the anterior drawer test will be posi-
collateral ligament, the medial capsular ligament, tive in all three rotational positions. A positive
and the posterior oblique ligament), the ACL, and posterior drawer test will be present if the PCL is
the posteromedial capsule generate this type of torn.
instability. A semimembranosus tendon injury
can be associated to this instability as minor or Straight posterior instability
major tears. Clinically, it is manifested by poste- This instability results from an isolated tear of the
rior rotation of the medial plateau on the femoral PCL. However, it might be injury to the arcuate
condyle. complex and to the posterior oblique ligament,
and the MCL, LCL, and ACL are intact. Clinically,
Combined anteromedial and anterolateral rotatory instability this instability is manifested by a markedly posi-
Th instability is produced by injury of the medial
This tive posterior drawer test with rotation.
and lateral supporting structures of the knee in
association with an ACL tear. Laterally, the mid- Straight anterior instability
dle third of the lateral capsule, the iliotibial band, Straight anterior instability is produced by an iso-
and the biceps tendon (short head) are torn. lated disruption of the ACL. Clinically, a positive
Physical examination is characterized by positive anterior drawer test in neutral rotation is present,
adduction stress, Lachman-Trillat, and anterior with no rotational displacement. Hughston con-
drawer tests. sidered straight anterior instability as an injury
related to the PCL. He emphasized that there can
Combined anterolateral and posterolateral rotatory instability
be no anterior displacement great enough to injure
This instability is produced by a disruption of all
the PCL without damaging the MCL and LCL.
lateral capsular structures associated or not with a
tear of the iliotibial band. Th
The PCL is intact and the
ACL is disrupted. Clinically, the adduction test is
markedly positive. The Th Lachman-Trillat and ante- Structural classifification
rior drawer tests are also positive. This classifi
fication is based on the anatomic struc-
Combined anteromedial and posteromedial rotatory instability tures that are damaged. The instability is classifi
fied as
This instability occurs as a result of medial and anterior, posterior, lateral, and medial (Table 4). This
posteromedial injuries associated to ACL and semi- classifi
fication is close to Hughston’s classifi
membranosus complex injury.

Straight instability Knee dislocation

Straight instability is defi
fined by an absence of
rotatory translation or subluxation as a result of Knee dislocation is defi
fined as a complete loss of
PCL injury. It is subdivided in four types: lateral, contact between the articular surfaces of the tibia
medial, anterior, and posterior. and the femur. There are several ways to classify
90 The Traumatic Knee

knee dislocations. Considering the fi

final position of lateral opening of the knee joint during valgus and
the tibia with respect to the femur, the dislocation varus stress testing, respectively. ThThe knee rota-
could be classifi
fied as anterior, posterior, medial, tion is guided by anteroposterior axes of femoral
lateral, or rotatory. (Table 1). However, this ana- condyles with respect to the plan formed by the
tomic classifi
fication is not useful when the knee non-injured tibial plateau.
dislocation is reduced as it happens in pentad inju- After the trauma, joint congruence is preserved
ries (17). with no residual translation of the tibial and fem-
oral joint surfaces. Many injury scenarios can be
Classifification system of Schenck – valgus force trauma® anteromedial triad (disrup-
tion of the medial structures and of a single cru-
Considering the injury pattern, as well as any asso- ciate ligament);
ciated neurovascular injury, a classifi
fication system – medial pentad (disruption of the medial struc-
has been described by Schenck (18): tures and of both cruciate ligaments);
– KD1: intact PCL with variable injury to collateral – varus force trauma® posterolateral triad (disrup-
ligaments; tion of the lateral structures and of a single cruci-
– KD2: both cruciate ligaments disrupted with ate ligament);
intact collateral ligaments (rare); – lateral pentad (disruption of the lateral struc-
– KD3: both cruciate ligaments disrupted with tures and of both cruciate ligaments);
medial or lateral ligament disrupted; – hyperextension trauma® posterior pentad (dis-
– KD4: both cruciate ligaments and both collateral ruption of both cruciate ligaments).
ligaments disrupted;
– KD5: knee dislocation with periarticular frac- Medial and both cruciate injuries (medial pentad)
ture. These injuries are the result of a valgus-external
This classifi
fication allows for establishing and orga- rotation trauma to the knee joint with the foot
nizing the clinical and surgical treatment of these fixed on the ground, leading to a disruption of the
injuries. MCL (medial gaping), posterior medial supporting
Another classifi fication was described during the structures, and both cruciate ligaments. Injuries
ESSKA’s Symposium and redefined fi in the 10th of the medial and lateral meniscus can be present
Journées Lyonnaises de Chirurgie du Genou to and, sometimes, associated to osteochondral frac-
contemplate the pentad injuries and knee disloca- tures of the lateral compartment. Exceptionally, an
tion. In this system of classification,
fi it is possible injury of the pes anserinus can occur (distal avul-
to identify the ligament injuries starting from the sion of the sartorius, gracilis, and semitendinousus
mechanism and the relative positions of the tibia tendons). Vascular complication is exceptionally
and femur (19,20). reported with this type of injury (Fig. 2A).

The pentads Lateral and both cruciate injuries (lateral pentad)

These injuries are produced by low-energy trauma, There are diff fferent clinical presentations for this
where the knee is submitted to a valgus, varus, or type of injury (Fig. 2B).
hyperextension trauma. First, a collateral ligament a. Anterolateral. This type of pentad results from ili-
disruption happens and is followed by the disrup- otibial band, LCL, and popliteus tendon ruptures.
tion of a cruciate ligament (triad) followed by the Frequently, the lateral meniscus is torn; however,
disruption of a second cruciate ligament (pentad). the posterolateral corner is intact.
The forces applied to one side of the knee joint b. Posterolateral. This type of pentad is created by
induce a collateral ligament disruption on the con- injuries of LCL, popliteus tendon, posterolateral
tralateral side. Clinically, this presents as medial or corner, and lateral meniscus.

Table 4 – Anatomic classification (Jacques Witvoët – Saint Louis Hospital 80).

Type of instability Injury
Only anterior Isolated LCA
Anterolateral ACL + anterolateral capsule
Anteromedial MCL + posteromedial corner ± ACL
Anterior global ACL + popliteus + posterolateral corner
Straight posterior PCL
Posterolateral PCL + LCL + posterolateral corner
Posterior-posterolateral PCL + LCL + popliteus + posterolateral corner
Classification of knee laxities 91

Table 5 – Combined bicruciate disruption: medial (lateral dislocation) or lateral (medial dislocation).
Bicruciate disruption Joint opening Subperiosteal detachment of the contralateral supporting structure
Medial (medial pentad) Medial Lateral
Lateral (lateral pentad) Lateral Medial

c. Hyperextension pentad. All lateral supporting struc- terior pentad. The tibia ends up in front of the
tures are disrupted (from iliotibial band to lateral femur by a phenomenon of anterior translation;
gastrocnemius). Clinically, it is manifested by an in some exceptional cases, this dislocation can
important lateral joint opening. An injury of the occur without a rupture of the PCL. The damage
sciatic popliteus nerve frequently happens result- of the popliteal artery is frequent in this type of
ing from the traction force. injury (Fig. 3A).

Posterior and both cruciate injury (posterior pentad) Pure posterior bicruciate injury (posterior dislocation)
The posterior pentad is produced by a trauma to This type of knee dislocation is a result of a vio-
the anterior aspect of the tibia or by knee hyperex- lent blow to the anterior part of the proximal tibia
tension secondary to a fall. In the latter case, one on a flexed knee or hyperextension. The posterior
can observe two mechanisms: the femoral condyles translation of the tibia is made possible by PCL dis-
resist and an impaction fracture of the anterior ruption. Seldom, a posterior translation can hap-
part of the tibial occurs, or the femoral condyles pen without any damage to the ACL.
break and a disruption of both cruciate ligaments In this type of knee dislocation, the tibia ends up
is observed. The following sequence is noted: a behind the femoral condyles. Sometimes, it can
rupture of the femoral condyles if the recurvatum be associated with a disruption of the patellar or
reaches 30°, a rupture of the ACL, then PCL and quadriceps tendon, a patellar fracture, or a lateral
also an injury of the popliteal artery if the recurva- dislocation of the patella resulting in an impor-
tum reaches 50° (6) (Fig. 2C). tant posterior translation of the tibia. The damage
of vascular structures was present in 25% of the
Dislocation cases (Fig. 3B).

Pure anterior bicruciate disruption (anterior dislocation) Combined bicruciate disruption: medial (lateral dislocation) or
The denomination of pure bicruciate disruption is lateral (medial dislocation)
proposed because, in cases of anterior dislocation These types are defifined by a bicruciate ligament
(but also posterior dislocation), it is completely disruption associated to an injury of one collateral
possible that the collateral ligaments remain in ligament. A detachment of the contralateral sup-
continuity in spite of the knee dislocation. ThThe porting structures is produced by the residual trau-
anterior bicruciate disruption generally occurs matic energy after the pentad injury has occurred.
after a movement of hyperextension and then In that context, the following sequences can be
follows the mechanism described in the pos- observed (Table 5; Fig. 3C and D).

Fig. 2 – Classification of pentads

92 The Traumatic Knee

Fig. 3 – Classification of Knee dislocation.

In this mechanism, a rotation occurs around an antero- Conclusion

posterior axis located in one compartment followed
by a translation toward this same compartment. In Those diff
fferent classifi
fications will be improved with
medial combined bicruciate disruption, we observe a new knowledge of knee kinematics. We may expect
rotation around an anteroposterior axis located in the that the classifi
fication system will be more precise
lateral compartment, followed by a lateral translation relating to ACL and PCL anatomy (double bundle)
of tibia that ends in lateral knee dislocation. In this and understanding of knee ligament injury.
pattern of injury, as in the medial pentad, we observe
the disruption of MCL, posteromedial supporting
structures, ACL, and PCL. Medial or lateral meniscus References
injury and an avulsion fracture of fibular
fi head can be
1. Fung YC (1993) The meaning of the constitutive equation.
present in these cases. A marked lateral translation In: Fung YC, editor. Biomechanics – mechanical properties
can be associated with knee extensor mechanism dis- of living tissues. New York: Springer: 23–65
ruptions and neurovascular injuries. 2. Woo SL, Abramowitch SD, Kilger R, Liang R (2006) Bio-
mechanics of knee ligaments: injury, healing, and repair.
Complex and combined bicruciate disruption J Biomech 39(1):1–20
3. American Orthopedic Society of Sports Medicine Research
This pattern of injury is produced by a bicruciate
and Education Committee: 1976.
disruption associated to medial and lateral support- 4. Andrews JR, Axe MJ (1985) The Th classifi
fication of knee liga-
ing structure disruptions. All the lesions not finding ment instability. Orthop Clin North Am. 16(1):69–82
description with the current classification,
fi such as 5. Daniel DM (1990) Diagnosis of ligament injury. In: Daniel
rotatory dislocations, can be placed in this category. DM, Akeson WA, O’Connor JJ, editors. Knee ligaments.
New York: Raven Press
In fact, in rotatory dislocations, there is often only 6. Hughston JC, Norwood LA (1980) The Th posterolateral
one element of the collateral supporting structures drawer test and external rotational recurvatum test for
(like the tendon of the muscle popliteus or the poster- posterolateral rotatory instability of the knee. Clin Orthop
olateral corner), which is respected and which remains 147:82–87
7. Noyes FR, Grood ES, Torzilli PA (1989) Current concepts
the only hinge linking the tibia with the femur. Vascu- review: the defi
finition of terms for motion and position of
lar injuries are frequent, and it is related to the great the knee and injuries of the ligaments. J Bone Joint Surg
displacement of the tibia under the femur (Fig. 3E). Am 71:465–472
Classification of knee laxities 93

8. Torg JS, Conrad W, Kalen V (1976) Clinical diagnosis of 15. Hughston JC, Andrews JR, Cross MJ, Moshi A (1976)
anterior cruciate ligament instability in the athlete. Am J Classifi
fication of knee ligament instabilities. Part I. The
Sports Med 4:84–93 medial compartment and cruciate ligaments. J Bone Joint
9. Galway RD, Beaupre A, MacIntosh DL (1972) Pivot shift: Surg Am 58:159–172
a clinical sign of symptomatic anterior cruciate insuffi-
ffi 16. Hughston JC, Andrews JR, Cross MJ, Moshi A (1976)
ciency. J Bone Joint Surg (BR) 54B:763–4 Classifi
fication of knee ligament instabilities. Part II. The
10. Matsumoto H (1990) Mechanism of the pivot shift. J lateral compartment. J Bone Joint Surg Am 58:173–179
Bone Joint Surg Br 72:816–821 17. Larson RL, Jones DC (1984) Dislocation and ligamentous
11. Noyes FR, Grood ES (1987) Classifi fication of ligament injuries of the knee. In: Rockwood CA, Jr., Green DP, edi-
injuries: why an anterolateral laxity or anteromedial lax- tors. Fractures in adults, 2nd ed, vol 2. Philadelphia: Lip-
ity is not a diagnostic entity? Instr Course Lect 36:185 pincott: 1, 480, 591
12. Dejour H, Walch G, Deschamps G, Chambat P (1987) 18. Schenck RC, Jr. (1994) The Th dislocated knee. American
Artrose du genou sur laxité chronique antérieure. Rev Chir Orthopaedic Surgeons Instr Course Lect 43:127–136
Orthop 73:151–170 19. Neyret Ph, Rongieras F, Versier G, Aït Si Selmi T (2002)
13. Jakob P, Hassler H, Staubli HU (1981) Observations on Physiopathologie, mécanismes et classification
fi des lésions
rotatory instability of the lateral compartment ot the bicroisées. In: Le genou du sportif. Paris: Sauramps Médi-
knee. Experimental studies on the functional anatomy cal: 375–386
and the patomechanism of the true and reversed pivot 20. Neyret Ph (1996) Lésions ligamentaires complexes
shift sign. Acta Orthop Scand Suppl 191:1–32 récentes: triades, pentades et luxations. In: Saillant G,
14. Dejour H, Walch G, Peyrot J, Eberhard Ph (1988) Histoire éd. Pathologies chirurgicales du genou du sportif. Cahiers
naturelle de la rupture du ligament croisé postérieur. Rev d’enseignement de la SOFCOT. Expansion Scientifique fi
Chir Orthop 74:35–43 Française, vol. 59, pp. 37–52.
Chapter 9

B.E. Heyworth, R.H. Brophy,

R.G. Marx
Scoring the knee

The use of knee rating scales for clinical outcomes tool, will be discussed. Finally, general
health status measures, joint and condition-spe-
outcome: historical perspective cifi
fic instruments, and measures of activity level

he move toward evidence-based medicine has will be detailed.
brought a new emphasis on the use of sound
outcome measures to evaluate patients and
the treatments provided to them. While the assess-
ment of orthopaedic surgical procedures dates
Properties of rating systems
back to the origins of the field,
fi the use of tradi- For any rating system to have value, it must be
tional measures of success following surgery, such both reproducible (“reliable”) and accurate (“valid”).
as physical examination and radiographic criteria, Because outcome tools assess health status, they
is now considered only one component of a com- must also detect changes over time (“responsiveness”
plete evaluation process. In the past three decades, or “sensitivity to change”), demonstrating improve-
outcome assessment following orthopaedic sur- ment or worsening in symptoms, disability, and/or
gery has focused increasingly on the perspective of function, either in the presence or in the absence of
the patient, rather than the surgeon. However, the a treatment intervention. Below we will discuss the
role of radiologic and physical exam parameters commonly utilized criteria of reliability, validity, and
remains pivotal, and patient-oriented outcomes responsiveness in rating systems.
must be viewed as having a critical, though com-
plimentary, role in analyzing the results of treat-
ment. Reliability
With the increasing significance
fi of assessment
and accountability, termed by one author as the If an outcomes instrument measures something
“third revolution” of health care (1), orthopaedic in a reproducible fashion, it is considered reliable.
surgeons and researchers have developed a num- Assessing the reliability, or reproducibility, of a rat-
ber of rating scales to assess patients with disor- ing scale usually entails surveying a stable patient
ders of the knee. The common goal of these scales twice or more in a short period of time, which
has been the estimation of patients’ symptoms should result in very similar or identical scores (2).
and disability caused by these knee disorders, and This is also known as test-test reliability.
the degree to which those disorders are addressed However, the appropriate time period between
by treatments. However, the impact on individu- administrations of surveys – usually from 2 days
als may vary widely, depending on the individual. to 2 weeks (3) – must be utilized. Too short of an
For example, an elderly patient with knee arthrosis interval between testing will allow a patient to
may have vastly diff
fferent degree of disability than remember their previous answer, while too long
an elite athlete with a ligamentous injury limiting of an interval may permit a subtle change in the
performance in competitive play. Therefore, rating patient’s health status.
systems must be judged not only on their ability to The statistical measures of reliability typically uti-
accurately assess changes in knee pain and mobil- lized are the intraclass correlation coefficient
ffi t (4,5)
ity but also on their appraisal of function within and/or the limits of agreement statistic (6–8). The Th
the realm of a given patient population’s goals for intraclass correlation coeffi
fficient is an index of con-
treatment. cordance for dimensional measurements ranging
This chapter will describe measures of clinical out- between zero and one, where ≥0.75 is considered
come that may be used to evaluate different
ff treat- appropriate for use in a clinical trial (9). It is impor-
ments for patients with disorders of the knee. ThThe tant to diff
fferentiate the intraclass correlation coef-
properties inherent in all rating systems, and the ficient from the Spearman or Pearson correlation
components that make for a sound and usable coeffi
fficients, which do nott measure agreement and
96 The Traumatic Knee

should not be used for studies of reliability. For rating scale, have been described. Criterion valid-
instance, if a first measure is twice as high as the ity involves comparing the results of a rating scale
second measure for all subjects in a study of reli- to an accepted “gold” standard. Although a simple
ability, correlation would be high but agreement form of survey validation, this is not applicable to
would be poor. The limit of agreement statistic is surveys that involve assessment of quality-of-life
a diff
fferent measure, equal to the mean diff fference (QOL) metrics, since there exists no gold standard.
between the two tests ± two standard deviations Face validity is present when an expert clinician
(7). Ninety-five
fi percent of the diff fferences between deems that a questionnaire’s components measure
the two tests will lie within this interval (7), pro- the overall concept being tested. Although simple,
viding the investigator with an estimate of the pre- face validity has an important role in the devel-
cision of the measure. opment of sound outcome tools. Content validity
One factor that may aff ffect reliability is the man- is similar to face validity, but measures whether
ner in which a knee scoring system is administered. a scale includes representative samples of the
Most outcome surveys are completed by patients, concept being measured. For example, if a rating
but may also be conducted by an interviewer in per- scale was measuring QOL, the content of the scale
son or over the telephone, and many studies have should include measures of physical, mental, and
utilized telephone surveys, due to the difficulties
ffi of social health to provide adequate content valid-
patient follow-up, particularly at longer time peri- ity. Construct validity determines whether a survey
ods. One study has shown that diff fferent scores may behaves in relation to other measures as would
be reported by the same patients, depending on be expected, via the development and testing of
the technique by which knee scoring systems are hypotheses regarding the positive or negative cor-
administered (10). However, these authors demon- relation of survey results with other related or
strated only a 3-point difffference in scores resulting unrelated measures or constructs.
from self-administration of the Lysholm knee scale,
compared to those resulting from completion of the
scale by an interviewer with the same patients on Responsiveness
the same day. While this difference
ff was found to
be statistically signifi
ficant, the clinical signifi ficance The use of rating scales in orthopaedic surgery is
of this diff
fference is questionable. Nevertheless, the most commonly geared toward assessment of oper-
findings underscore the importance of consistency ative or non-operative interventions. Therefore,
in the methods of collection of outcome measures. only instruments that are able to measure improve-
Another method for assessing reliability is known ment in health-related QOL following treatment
as internal consistency. Internal consistency is com- are useful. This is the quality of responsiveness, for
monly reported in the field of psychometrics, a which there are many statistics (15,16). TheTh most
discipline concerned with the study of educational commonly utilized statistic in orthopaedic surgery
and psychological differences
ff between individuals research is called the standardized response mean,
or groups of individuals, such as those determined which is calculated by the observed change divided
by knowledge, attitude, aptitude, and personality by the standard deviation of change (17–19). By
traits (11). Unlike test-test reliability, calculating incorporating the standard deviation in the statis-
internal consistency involves the inter-correlation tic, the response variance is considered and allows
of responses to survey questions on a single admin- for testing of the response means (20).
istration, and is described by Cronbach’s alpha,
which ranges from zero to one, with one indicat-
ing perfect reliability (12). While Cronbach’s alpha Quality of life
has been used to evaluate the reliability of a knee
rating scale (13), the application of psychometric While the properties of reliability, validity, and
principles to the measurement of symptoms and responsiveness of a rating scale are critical fea-
disability remains in question. In practice, ortho- tures of their design, increasing attention has also
paedic surveys have been shown to have a high been paid in the past two decades toward the abil-
Cronbach’s alpha value when they measure a wide ity of an outcome measure to incorporate patients’
range of clinical phenomena (14). perspectives on their knee conditions or interven-
tions (3). Subjective sections of knee scales, which
include questions completed by the patients, have
Validity been emphasized as a means by which the scale
measures the frequency and severity of symptoms
Validity is the ability of an instrument to measure and patient function, and, in turn, the degree to
what it is designed to measure. Several different
ff which a patient’s QOL is aff ffected. A recent study
types of validity, or approaches to validation of a by Tanner et al. analyzed the subjective sections of
Scoring the knee 97

11 knee-specifi
fic instruments in 153 patients with By contrast, disease-specific,
fi condition-specifi fic, or
anterior cruciate ligament (ACL) ruptures, isolated joint-specifi
fic measures have the advantage of being
meniscal tears, or osteoarthritis to investigate how generally more responsive to change in a specific fi
ffectively they assessed QOL (21). They demon- phenomenon, as well as being more relevant to a
strated a wide range in the ability of knee scales to specifi
fic group of patients. Thus a patient’s symp-
measure patients’ interpretation of their injury or toms or complaints can be attributed more directly
condition and their perceived improvement expe- to the disorder of interest than a more global
rienced following an intervention, citing different
ff health measure (22,31). For example, a joint-spe-
instruments as being most effffective for evaluating cifi
fic instrument for the knee may ask patients if
QOL in each of the three conditions. Clearly, con- they have diffi
fficulty getting dressed due to their knee
siderations toward the property of QOL assessment problem.
will gain only greater importance in the future, as
new scales are developed and existing scales are
enhanced, with emphasis on the larger goal of Knee rating scales for athletic patients
improving patients’ global health and QOL.
A number of diff fferent scales have been developed
to assess outcome in athletic patients with knee
disorders. While there is a wide range in levels of
Outcome tools for the knee competition and activity levels amongst athletes,
nine of the most commonly used knee rating scales
When considering the variety of outcome tools for athletic patients are described below, most of
that may be used in assessment of disorders of which have been applied to a variety of athletic
the knee and their treatments, it is important sub-populations.
to remember the goals of intervention. Not only The modified
fi Lysholm knee scale (32) is an eight-
should a procedure have a positive effect
ff on the item questionnaire that was designed in 1982 and
patient’s symptoms, but that effect
ff should also subsequently modifi fied 3 years later to evaluate
translate into improvements in the patient’s activ- patients following knee ligament surgery (33). Th The
ity level, general health, and QOL. The range of 100-point scale is divided into 25 possible points
scoring instruments, from general to specific,
fi are for knee stability, 25 for pain, 15 for locking, 10
therefore reviewed, with an emphasis on the goals each for swelling and stair climbing, and 5 each
of each and their applicability to the various sub- for limp, use of a support, and squatting (32). ThThe
sets of patients with knee disorders. Lysholm scale, which has been used extensively
for clinical research studies (30,34–36), has been
demonstrated to have adequate test-retest reliabil-
Generic and specific
fi outcome tools ity and construct validity not only for evaluating
patients with injuries and treatment for ligamen-
Generic health status outcome tools have been tous disorders of the knee but also for patients with
used with increasing frequency in orthopaedic chondral and meniscal injuries as well (33,37–39).
surgery in recent years. By incorporating a broader Modififications of the Cincinnati Knee Rating System,
perspective of health, including emotional, social, first published in 1983, incorporated additional
mental, and physical components, rather than questions that considered occupational activi-
attribution to a particular disorder, these instru- ties, athletic activities, symptoms, and functional
ments allow comparisons across conditions and limitations with sports and daily activities (40,41).
treatments (22,23). The
Th drawback of these sur- Among the instrument’s 11 components are sec-
veys is that they are generally less responsive to tions for physical examination findings, laxity of
clinically important change because a change in the knee based on instrumented testing, and radio-
an isolated problem may not be reflected
fl in the graphic evidence of degenerative joint disease (42).
score of the more global measure (22,24–26). By This instrument is reliable, valid, and responsive to
far the most commonly used generic health sta- clinical change (39,42).
tus instrument is the SF-36, a 36-item question- The American Academy of Orthopaedic Surgeons
naire that allows for a measurement of a patient’s (AAOS) Sports Knee Rating Scale (43), was pub-
general health, and from which either a physical lished in 1998 as part of the Musculoskeletal Out-
component scale (PCS) or a mental component comes Data Evaluation and Management System
scale (MCS) can be derived (27–29). Th The use of (MODEMS). It contains 23 questions in five fi sub-
the SF-36 is encouraged as a compliment to knee- sections – designed to be reported separately –
fic instruments for studies of ACL-injured which evaluate the following metrics: (1) stiffness,
patients (30)and for patients undergoing total swelling, pain, and function (seven questions); (2)
knee arthroplasty (22). a locking or catching during activity (four ques-
98 The Traumatic Knee

tions); (3) giving way during activity (four ques- considers symptoms, physical complaints, work-
tions); (4) current activity limitations due to the related concerns, recreational activities, sports
knee (four questions); (5) pain during activity due participation, lifestyle, and social and emotional
to the knee (four questions). When the fi five sub- health status as they relate to the knee. However,
scales are combined for a calculated mean, the the measure is limited by its narrow role in the
measurement properties of this instrument were assessment of ACL-defi ficient patients, for whom it
found to be satisfactory (39). However, one practi- has been shown to have satisfactory validity and
cal limitation of the instrument is its inclusion of a responsiveness (47).
possible response of “cannot do for other reasons” In 1993, the International Knee Documentation
for many questions. The scoring manual states that Committee (IKDC) presented a seven-parameter
such an item should be “dropped” for this response, scale in which the clinician or “observer” graded
which may be interpreted as a missing score (39). each of the following as normal, nearly normal,
Th Activities of Daily Living Scale of the Knee Out-
The abnormal, or severely abnormal: effusion,
ff motion,
come Survey, designed to assess outcome in patients ligament laxity, crepitus, harvest site pathology,
with knee arthrosis as well as various sports-related x-ray findings, and one-leg hop test (48). This scale
injuries and disorders, has a 7-question section for was unique in that it was designed to be applied
symptoms and a 10-question section for functional more broadly to a wider range of knee disorders
disability. Analysis has demonstrated good reliabil- than most of the other, more specific fi scales, as well
ity, excellent construct validity, and higher rates of as the approach utilized for scoring, in which the
responsiveness than the Lysholm, Cincinnati, and lowest grade for a parameter determines the final fi
AAOS scales (13,39). The questions that make up patient grade. More recently, the IKDC Subjective
this tool are presented in Appendix A. Knee Form was synthesized. Like the initial form,
Th Single Assessment Numeric Evaluation (SANE)
The it was constructed to be knee specific, fi rather than
is a uniquely simple rating scale in which patients disease specific.
fi However, the score was deter-
are asked to rate their knee, from 0 to 100, with mined exclusively from patient responses to ques-
100 being normal. While the wider applicability tions regarding knee symptoms, sports activities,
of the instrument for a range of knee disorders and functional abilities, such as walking stairs,
remains unclear, its utility for evaluating college- squatting, running, and jumping. Validation and
age patients following ACL reconstruction has reliability studies showed internal consistency and
been borne out in one study showing high corre- test-retest reliability of 0.92 and 0.95, respectively,
lation with the Lysholm scale in this narrow sub- as well as a correlation to concurrent measures of
population, which it was designed to study (44). physical function (rr = 0.47 to 0.66) (49). Not only
The Knee Injury and Osteoarthritis Outcome Score does the IKDC Subjective Knee Form allow com-
(KOOS) was developed with input from patients parisons of outcome across groups with differentff
who underwent meniscal surgery, but has also been knee problems, newly published normative data,
shown to have adequate reliability, validity, and calculated from a compilation of scores for 5246
responsiveness in patients undergoing ACL recon- knees from the general population, will allow for
struction (45). There
Th are five diff
fferent sections in comparisons of patient scores to age- and gender-
the instrument, specifi fically those for pain, symp- matched peers (50).
toms, activities of daily living, sport, and recreation
function and knee-related QOL. One benefit fi of the
KOOS is that the Western Ontario and McMaster Knee rating scales for patients with degenerative
Universities Osteoarthritis Index (WOMAC) scale, disorders of the knee
a commonly used instrument for assessing outcome
in patients with osteoarthritis, is included in, and Outcome measures geared toward assessment of
can be determined from, the KOOS. A recent study knee arthritis or other degenerative knee disor-
analyzing outcomes in patients with a mean age ders tend to diff
ffer slightly from those investigating
of 71 having undergone total knee replacements knee symptoms and function in athletic patients,
(TKRs) suggested that the KOOS had similar or in that they survey greater degrees of disability,
improved validity and responsiveness, compared to overall.
the WOMAC, suggesting its applicability to a very In one of the first outcome studies on TKR, Rana-
fferent patient population (46). wat and Shine presented a new scale from the Hos-
Developed in 1998, the quality of life outcome mea- pital for Special Surgery for “knee disability assess-
sure for chronic anterior cruciate ligament defificiency ment” in 1973 (51). Three years later the scale was
has 31 questions constructed by surveying ACL- modifified slightly and presented in a study by Insall
ficient patients, primary care sports medicine et al. (52), which compared outcomes following
physicians, orthopaedic surgeons, athletic thera- four difffferent models of TKR prostheses. What
pists, and physical therapists (47). The
Th instrument became known as the HSS Knee Scale has a maxi-
Scoring the knee 99

mum score of 100 points, with 30 for pain, 22 for (68). Therefore, a number of activity level rating
function, 18 for range of motion, 10 for strength, scales have been developed, generally to be used in
10 for flexion deformity, 10 for instability, and sub- conjunction with outcome instruments. Use of these
tractions for walking aids, extension lag, or varus/ scales is critical not only to differentiate
ff athletic
valgus deformity. Total scores are divided into patients from more sedentary arthritis patients but
“excellent” (>85), “good” (70–84), “fair” (60–69), also to make distinctions within subgroups, such as
or “poor” (<60). While some feel the HSS Knee Scale highly active post-arthroplasty patients from house-
has been superceded by more recently developed hold ambulators or middle-aged “weekend warriors”
instruments (23), overall it has been shown to from elite professional athletes, each of which may
have good interobserver reliability (53) and is one warrant separate analysis.
of the most commonly utilized scales in knee sur- One of the most commonly utilized activity level
gery (23). Moreover, its use has extended beyond rating scales is the Tegner Activity Scale, which
patients with knee arthritis, including assessment was introduced in 1985 as a complement to the
of operative and non-operative treatment of ACL Lysholm functional outcome measure for patients
rupture (54–56). treated for knee ligament instability (32). Th The
The American Knee Society Score (AKS) is an out- Tegner score ranges from 0 to 10, with 10 repre-
come measure instrument developed by Insall et senting participation in elite, competitive sports
al. in 1989 (57), in which trained assessors evalu- and 6 in recreational sports. In addition to its role
ate candidates for knee arthroplasty or post-TKR in assessing patients with ligamentous knee injury,
patients. It features two parts: the knee score, the Tegner Activity Scale has been shown to have
in which pain, stability, and range of motion are reliability, validity, and responsiveness for patients
considered, and the function score, of which walk- with a meniscal injury of the knee (37).
ing distance and stair climbing are the most sig- Interestingly, a recent systematic literature review
ficant parameters. The use of this tool is limited (68) analyzed five activity level rating scales that
by its need for administration by an experienced are potentially applicable to outcome studies in
observer, such as a clinician trained in arthroplasty sports (32,69–72). Inherent problems with each
surgery, a limitation borne out by an interobserver of the instruments were discussed, including those
reliability study in which scoring by assessors with with the Tegner Activity Scale. As a result, a new
varying levels of training was analyzed (58). rating scale – with four questions on the frequency
Like the AKS, the index of severity for osteoarthritis of of running, cutting, pivoting, and decelerating –
the knee (59) was developed in 1987 as an observer- was developed specifi fically for knee outcome stud-
administered questionnaire. However, a validated ies in the athletic population (68). It has been
version allowing for independent patient comple- demonstrated to be reliable and valid (68). Since
tion (60) has made the survey (also referred to as its introduction in 2001, a number of studies have
the Lequesne-algofunctional index)x more applicable. referenced the scale in analysis of outcomes related
It contains five pain questions, one walking ques- to knee interventions (37,73–75). It has also been
tion, and four activities of daily living questions, cited as a model in studies proposing activity scales
and is therefore relatively short and easy to use. for the ankle (76) and shoulder (77).
The Oxford Knee Scale (OKS) includes 12 multiple- More recently, a lower-extremity activity scale
choice questions, each with 5 responses. It has (LEAS) designed to measure activity levels among
been demonstrated, with a prospective group of a broader population of patients, including those
117 patients undergoing TKA, to be reliable, valid, undergoing knee arthroplasty, was developed (75).
and responsive (61–63). The LEAS was constructed to refl flect four major
The Western Ontario and McMaster Universities levels of lower extremity activity: (1) housebound
Osteoarthritis Index (WOMAC) (64–66) includes 5 (minimal ability or inability to walk), (2) ordinary
questions relating to pain, 2 relating to stiffness,
ff walking about the house, (3) walking about the
and 17 relating to diffi
fficulty with activities of daily community, and (4) walking about the commu-
living (see Appendix B). The
Th scale is the most fre- nity and substantial work or exercise. Saleh et al.
quently used scale for arthrosis, for which it has demonstrated high responsiveness, reliability, and
high responsiveness and validity (22,60,67). validity in a cohort of patients who underwent
revision total knee arthroplasty (75).

Measures of activity level for patients with disorders

of the knee Knee rating scales: the international perspective
For studies comparing two groups of patients, it is A recent surge of literature has emerged in which
important for the activity levels of the two groups translations, validations, and cross-cultural adap-
to be similar in order to avoid a biased comparison tation of English-language-based knee scores
100 The Traumatic Knee

are performed (62,78–81). For example, the become more widely accepted and broadly incorpo-
WOMAC scale has been translated into a num- rated into the subspecialty of orthopaedic surgery
ber of languages with accompanying validation and the field of health care at large, such an under-
analyses (62,64,79). This
Th is an important trend, standing will not only enhance one’s skill set but
in part because it permits enrollment of foreign- also help to improve the delivery of health care to
speaking patients into studies in English-speak- those in need.
ing countries. More importantly, surgeons and
researchers throughout the international ortho-
paedic and rheumatologic community are able References
to utilize common analytical tools in outcome
research, and their results become more broadly 1. Relman AS (1988) Assessment and accountability:
the third revolution in medical care. N Engl J Med
interpretable and applicable to a larger health 319(18):1220–1222
care population. 2. Streiner DL, Norman GR (1989) Health measurement
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A wide variety of knee scoring systems have been 4. Bartko JJ (1966) The
Th intraclass correlation coeffi
fficient as a
developed for use by clinicians and researchers measure of reliability. Psychol Rep 19(1):3–11
alike. We have summarized the knee scoring sys- 5. Deyo RA, Diehr P, Patrick DL (1991) Reproducibility
and responsiveness of health status measures: statistics
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fficient in the evaluation of
trial to a simple follow-up assessment in the office.
ffi agreement between two methods of measurement. Com-
As evidence-based medicine practices continue to put Biol Med 20(5):337–340

Table 1 – Scoring system for the knee.

Scoring Systems for the Knee
Category Scoring System Introduction Brief Description
General Short Form 36 (SF-36) 1993 Generic measure of general health
Modified Lysholm Scale 1985 Emphases on ligament stability, pain
Cincinnati Knee Rating System 1983 Diverse measures for athletic patients
AAOS Sports Knee Rating Scale 1998 Specific component of the more generic MODEMS
Sports- ADL Scale of the Knee Outcome Survey 1998 Impact of range of disorders on activities of daily living
Related Knee
Single Assessment Numeric Evaluation (SANE) 2000 Specific for college-age patients undergoing ACL surgery
Injuries &
Conditions Knee Injury and Osteoarthritis Outcome Score (KOOS) 1998 Assesses pain, symptoms, sport/recreation function, quality of life
Quality of Life for Chronic ACL Deficiency 1998 Very specific measure for non-op pts
International Knee Documentation Committee (IKDC) 1993 Seven 'objective' parameters; lowest score used
IKDC Subjective Knee Form 2001 Assesses symptoms, sports activities and ability to function
West. Ontario/McMaster U. Osteoarthritis Index (WOMAC) 1998 Most commonly used scale for osteoarthritis
Index of Severity for Knee Disease 1987 Developed for NSAID clinical trials
Knee MODEMS Knee Core Rating Scale 1998 Subset of MODEMS specific for osteoarthritis
Disease & Oxford Knee Scale 1998 Developed for patients undergoing total knee arthroplasty
American Knee Society (AKS) Scale 1989 Interviewer assesses TKR candidates or post-op patients
Hospital for Special Surgery (HSS) Knee Score 1973 Assesses pain, function, ROM, strength, deformity, stability
Tegner Activity Scale 1985 Determines patients' activity level; used w/ outcome scores
Marx Activity Scale 2001 Assesses running, cutting, pivoting, and decelerating
Lower-Extremity Activity Scale (LEAS) 2005 Assesses activity in patients undergoing TKR
Scoring the knee 101

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Appendix A – Activities of daily living scale 103

Appendix A – Activities of daily living scale

104 The Traumatic Knee
Appendix B – Womac knee scale 105

Appendix B – Womac knee scale

The Menisci
Chapter 10

J.C. Panisset, J.L. Prudhon Arthroscopic meniscectomy

Summary Installation

he basic principles of arthroscopic menis-
cectomy are described. After reminding the Tourniquet
fferent installations and the diff
fferent ens-
sential and complementary instruments, menis- Its use has become systematic for a better sur-
cectomy techniques are described making the dif- geon comfort. Actually, by avoiding any bleeding
ference between the lateral meniscectomy and the we improve the intra-joint visibility. Nevertheless,
medial meniscectomy. several studies (2–4) have shown that muscular
cells could be altered, which is proved by electro-
myographic modifications.
fi These alterations are
visible among 22% of patients after 15 min of tour-
Introduction niquet and among 80% of patients after 60 min of
tourniquet, which is an exceptional case after a
The knee arthroscopy (1) <Comp: Delete the meniscectomy. The revolving to normal state can
endnotes, in superscript, once the reference last for several months (5–6 months), without any
list is properly styled.>is successful thanks to long-term damage.
the first pioneers and meniscectomy is no more Some studies have shown (5) that the use of tour-
achieved through arthrotomy anymore. This
niquet was increasing the post-surgery pains and
technical procedure requires a long training to
the risk of post-surgery complications and, above
get a great efficiency and an innocuous menis-
all, had a negative effffect on physiotherapy, essen-
cectomy implementation. An important learn-
tially from the muscular sideration.
ing curve is needed to achieve easily and safely a
meniscectomy for the patient. The bases of this So, it is absolutely possible and better to achieve a
surgery must be accurately acquired to answer meniscectomy without any tourniquet, above all,
to the different pathologic situations of the after a period of training.
meniscus. Therefore, the use of tourniquet must last a
We have made the difference between the medial short time. Obviously, the counter-indications
meniscectomy and the lateral meniscectomy, must be respected, such as the vascular ante-
which must be carried out differently since they cedents. An irrigation of good quality must be
have their own characteristics. Actually, the por- respected to allow a good intra-joint visibility
tals are not the same, and the installation may with or without tourniquet. The current use of
be slightly different. Postoperative management an arthro-pump can also be an alternative to the
is also not comparable. Arthroscopy for menis- tourniquet use.
cectomies remains a surgical procedure with
possible risks. These risks must be precisely
assessed and explained to the patient. To con- The installation
clude, a meniscectomy will only be carried out
after an accurate diagnosis, requiring modern There are two main possible installations, accord-
imagery; arthrography, arthro-scanner, and ing to the surgeon habits:
MRI. The expected time for recovery is short, – Patient is installed in dorsal decubitus, the leg
but long terms consequences will be explained being free at the end of the table, with the thigh
to the patient. fastened.
– Patient supine the lower limb lying down on
the table, with a wedge on the lateral side of the
thigh, and another wedge at the end of the foot
(Fig. 1).
110 The Traumatic Knee

Fig. 1 – classical installation , patient in dorsal decubitus. Fig. 2 – Valgus constraint to open the medial compartment.
Each of these installations has its own advantages niquet. This pressure must be weak to avoid any
and disadvantages. risk of compartmental syndrome.
• The pendent leg position enables to carry out The first technique is the most often used for a
an arthroscopy without any lateral help, and the meniscectomy since it enables a suffi fficient rinsing
thigh fixation permits a good control of rota- out of the joint. Th
The second benefi
fit is to be economi-
tions that is very important in meniscectomies. cal too. The arthro-pump is often used with a shaver,
The exploration of the lateral compartment is so the indication will depend on the use of this tool,
made without the Cabot handling, which tends which is quite useful in degenerative lesions.
to obstruct the irrigation of this compartment.
Nevertheless, patello-femoral joint exploration is
fficult and requires an extension of the patient’s The instrumentation
foot against the examiner. On the other hand,
there are more important asepsis mistakes due to Equipment has highly evolved since the origin of
the low position of the foot. arthroscopy. To achieve a meniscectomy, few tools
• The position of the lying leg enables an excellent are required. They must be chosen with care and
vision of the femoro-patellar joint; it requires experimented before purchase, because of their
the Cabot handling for the exploration of the lat- high cost.
eral compartment and procedures on the lateral We have the choice between motorized tools
meniscus. This Cabot handling is achieved by put- (shaver), whose use in meniscectomies is not
ting the foot on the opposed knee, while imposing compulsory. Arthroscopic optics and a camera are
a flexion and a slight varus constraint. The whole unavoidable. The ideal optics is generally a great
lateral meniscus is visualized by this technique. angular optics (25° or 30°), and a 70° optics is
For the exploration of the medial meniscus, a val- rarely necessary. The
Th optics will be selected to be
gus constraint is held by positioning the foot on autoclave to answer to the modern specifications
the arthroscopist’s hip. Thus, by playing with the of sterilization. The camera will be mono CCD or
flexion and extension of the knee, the exploration
fl three CCD type. TheTh first type is highly suffi
of the medial compartment is carried out without for the meniscectomy procedures. Arthro trocar
any diffi
fficulty. We must keep moderated on the sleeve enables the penetration of the optics in the
valgus constraints as the developed strength can knee and the frontal irrigation opposite the arthro-
be important and risks of medial collateral liga- scope itself, which improves the display.
ment lesions are possible (Picture 2).
Non-motorized tools
The palpater hook is the first instrument that is
Irrigation introduced into the knee by the instrumental por-
tal. There must be a 3-mm mossy hook at its end
There are two possibilities to achieve a meniscec- to palpate without producing cartilage injuries.
tomy: It must be suffi
fficiently rigid to enable a meniscus
– Simple irrigation by gravity using physiological reduction. Thanks to its size, we can assess the
salt solution, which drip is placed at a high level spread and the depth of injuries. With the gradu-
to get a good intra-joint pressure; in addition, a ations on its surface, we can appreciate the size of
blood pressure cuff
ff could be interesting. the lesions.
– Arthro-pump, which enables a constant pressure Basket forceps, named rongeurs, are unavoid-
in the joint, the pressure adjusted on the blood able since they enable to perform or to complete
pressure, limiting the bleeding in case of no tour- a meniscectomy. Many types come to the market
Arthroscopic meniscectomy 111

with difffferent sizes, diff

fferent shapes, and several be regularly checked up and sharpened, to avoid
angulations. any surprise along the intervention, modifying the
The basic surgery box must contain a right 3.5-mm surgical procedure and its length.
forceps that can reach the posterior segment and a
90° angled forceps working on the meniscus ante- Motorized tools
rior segment. It can be completed with bigger ron- The shaver is not compulsory to carry out a menis-
geurs of 4.5 and 5 mm, providing a faster splitting cectomy. Meanwhile, it enables to straighten the
up of the meniscus tissue, in the most easily acces- meniscus wall, to complete a difficult
ffi meniscec-
sible zones. tomy of the posterior segment of the medial or
Many rongeurs come to the market; with distal lateral meniscus. Its use is more interesting in the
angulations, with a handle curved to the right or lateral meniscus cysts that can be treated by intra-
to the left. These diff fferent types of rongeurs are joint portal. At last, it permits to straighten a fl
very practical and can perform an easier meniscec- located on the lower side or to neaten an anterior
tomy. Their use is not unavoidable, and their cost segment of the lateral meniscus.
is high. The motorized blades are alternatively used, which
The most useful rongeur is the one which permits to enables the spontaneous throwing away of menis-
slide under the condyle without the risks of produc- cus parts. They are small to slide under the con-
ing cartilage lesions. For this purpose, it must be of dyles without damaging cartilage. Some blades can
double curve with upper concavity in its distal third. be twisted.
It is commonly named «curved on the fl flat side». The laser use to achieve a meniscectomy is more
Scissors are useful to start a meniscectomy in and more reported. Since it is expensive, its use
medium segment elegantly, their use is not advis- is not common. Its harmlessness is not proven;
able in posterior segment since they are very cartilage injuries can occur after a too long use,
bulky and the cartilage lesion risk is high. Th There and they depend on the dose (energy) and length
are straight scissors and angled scissors at their of the use. The meniscectomy is implemented by
end to choose a more accurate and proper angle. A cauterization. This technique is not yet common,
3.5-mm diameter seems to be a good compromise so works are being carried out to precise modifica-
between effi fficiency and low bulking. tions and eff
ffects of laser on cartilage.
The forceps is essential; this forceps in its prin- The first studies achieved in the departments of
ciple presents two small teeth at its ends, which Prof. Beaufifils and Prof. Benoît since 1992 had
are going to bite the meniscus. It is aimed either to shown the immediate harmlessness and effi fficiency
remove a free fragment from the joint or to draw of laser Ho:Yag. This retrospective study showed
the meniscus that is not still detached (three-por- the superiority of laser meniscectomy vs. the clas-
tal technique). Its use is only recommended in the sical arthroscopic technique. A randomized study
anterior compartment of the joint. Actually, since carried out by Blin and colleagues (7) in 1995, com-
it is bulky, its passage through the condyle is lim- paring mechanical arthroscopic meniscectomy and
ited. It is advisable to select a forceps whose open- laser meniscectomy, did not show the superiority
ing and closing can be done with only two fingers of laser to achieve an arthroscopic meniscectomy.
either from the left hand or from the right hand. Laser can represent an extra advantage in certain
The meniscotomes are straight or curved. Also cases such as locked knees, but its excessive cost
named tenotomes or Smillie scissors, their use and its limited use must not justify such a pur-
mainly concerns the three-portal technique. So, chase. We are unaware of the long-term effect ff on
the meniscus excision is performed on a drawn cartilage and under-chondral bone.
meniscus. One must be cautious while using
these instruments; it is advisable to have very
sharp scissors to avoid any escape and a poste-
rior escape in particular, which could be brought Medial meniscectomies
about by an excessive pressure on the instrument.
That is why single-use tenotomes exist where the
blade can be replaced as a bistouri blade. As ever Fundamentals
in surgery, any strain on these instruments must
be avoided. We can find also 90° angled menisco- Before deciding a medial meniscectomy, it is highly
tomes that can be useful in diffi fficult conditions, recommended to have a precise diagnosis of the
on an anterior segment of the lateral meniscus type of lesion of this meniscus and its location. It
for instance. is even very important to precise exactly the car-
These instruments represent the minimum for a tilage state of the knee. These
Th precautions enable
meniscectomy, possibly completed according to to warn the patient about the surgery follow-ups.
the practices of the surgeon. Th The instruments must A retrospective study (8) that we have carried
112 The Traumatic Knee

out with the Société Française d’Arthroscopie – With the patient over 50 years: the simple x-ray
has shown the evolution of meniscectomies over standing up with a schuss x-ray will enable to
15 years. This study has shown that there were determine a posterior narrowing (Picture 5).
22% of radiographic abnormalities concerning a Complementary examinations will be discussed
medial femoro-tibial reshape or an interline nar- according to the context. An arthro-scanner is
rowing. The long-term result is much better with a ideal to target cartilage lesions and their depth and
young patient, with a traumatic lesion and a con- spread. But an MRI is interesting (9) to avoid an
servation of the meniscus wall without any carti- osteonecrosis of the medial condyle, which can be
lage lesion. a diff
fferential diagnosis of the degenerative medial
This is to say, we must extremely be cautious to
Th meniscus lesion.
carry out a meniscectomy for a patient older than These precautions will enable to perform a menis-
50 years. This indication should only be done in cectomy in the best conditions by limiting the risks
case of the uneffifficiency of a good medical treat- of complications (10).
ment. The employed technique depends on the operator
Therefore, it is recommended to perform paraclini- habit and on the meniscus lesion type. Two previ-
cal examinations before any minescectomy: ous procedures must be solved before starting the
– With the patient younger than 50 years: simple meniscectomy:
face and profifile x-ray with monopodal stand up – Adjusted meniscectomy or splitting up
and a 30° axial view of the patella. An arthro- – Partial or subtotal meniscectomy
TDM or an MRI enable to precise the meniscus Several studies (11,12) have shown that there
lesion (Pictures 3 and 4). was a direct relation between the long-term result
and the importance of the meniscectomy. Th This is
an important argument to achieve “economical”
In most of the cases, it is advisable to remove the
meniscus lesion as a whole. This is easy when it is a
bucket handle. In other cases, the progressive split-
ting up by rongeurs is necessary. Very often there is an
association of the two techniques. Th The meniscus tis-
sue must be left sound and safe by the meniscectomy.
The meniscectomy is said to be total if it concerns
the capsule-meniscus junction, i.e., if the meniscus
wall is removed. Trillat (13,14) has shown that it
was important to keep the meniscus wall by per-
forming an intra-wall meniscectomy. Th The menis-
cectomy is said to be partial when a good meniscus
wall is left. It is the basic technique, and it enables
to remove the mobile part and leaves a stable
Picture 3 – arthro-TDM vertical medial meniscus tear. meniscus remnant.
The meniscectomy is performed as far as the cir-
cular fibers of the meniscus wall. We speak of a

Picture 4 – MRI and medial meniscus lesion. Picture 5 – Schuss X Ray, medial narrowing.
Arthroscopic meniscectomy 113

subtotal meniscectomy when the importance of along the medial condyle, then in the intercondylar
the lesion requires the excision as far as the menis- notch, and finally in the lateral femoro-tibial com-
cus wall of an important functional segment of a partment in the Cabot position. This exploration is
meniscus, for instance, a posterior segment. very important; it must be performed before doing
fils (15) has risen this problem of a «partial
P. Beaufi the second instrumental portal. It enables to pre-
meniscectomy» and suggests to use a terminology cise the type of lesion and mainly its importance. It
making reference, on the one hand, to the inter- enables to check the cartilage state and a possible
ested segments and, on the other hand, to the diffi
fficulty to set the knee into forced valgus.
meniscus excision quantity for each segment. Th The The antero-medial portal will be performed by
excision of the whole back segment of the medial trans-illumination in the dihedral antero-medial
meniscus is called total meniscectomy of the pos- angle above the anterior segment of the medial
terior segment and not partial meniscectomy. meniscus. Then the palpater will be introduced and
This terminology is very important for the writing palpate both menisci on their two sides by lifting
of the surgical report and to assess the evolution. them and the two cruciate ligaments. The Th antero-
medial portal will be more or less high and medial
according to the lesion localization.
Bucket handle and vertical longitudinal lesion (Picture 7)
It is a standard to oppose the two-portal technique The two-portal technique needs only one instru-
and the three-portal technique. ment, the arthroscope being in the second portal.
To treat a dislocated bucket handle of the medial
Two-portal technique (Picture 6) meniscus with this technique, we must perform
Th antero-medial and antero-lateral portals are
The the following:
fficient to achieve the majority of medial menis- (a) Reduce the meniscus lesion with the hook
cectomies. (Fig. 1).
First, the antero-lateral portal will be performed to The arthroscope is introduced through the antero-
introduce the arthro-trocar sleeve and the arthro- lateral portal. The palpater is introduced through
scope. This portal will be performed in the dihedral the antero-medial portal, the reduction is per-
angle formed by the lateral edge of the inside patel- formed by a pressure at the top of the handle and
lar tendon and the point of the patella up at 1.5 cm by a slight valgus strain at the tibia level, and the
from the upper edge of the lateral tibial plateau. increase of the flexion is often necessary to achieve
Arthro trocar sleeve will be introduced after cut- the reduction.
ting the skin and the patella with a bistouri. The Th (b) Cut the posterior part at the posterior segment
arthro trocar sleeve will be directed to the inter- levels (Fig. 2).
condylar notch, the knee being flexed
fl at 30° or 45°. This procedure is performed by the antero-medial
Then, the arthroscope will be directed to the knee portal, with a rongeur, a bistouri, or a tenotome.
femoro-patellar joint, knee being in extension, It is advisable to leave a small flap to avoid the
to start the knee exploration. The Th latter will be
systematic, with the following exploration in the
medial femoro-tibial compartment by going down

Picture 6 – two portal approach, medial portal for arthroscope and lateral
portal for other tools. Picture 7 – Bucket handle of medial meniscus.
114 The Traumatic Knee

Fig. 1

Fig. 2
Fig. 3
escape of the meniscus once the anterior part is
being cut. This procedure is more easily done with
a valgus strain on the tibia to open the medial
compartment. Thus, the arthroscope goes more
deeply into the medial compartment giving a
higher visibility of the posterior segment of the
medial meniscus.
(c) Cut the anterior part (Figs. 3 and 4).
There are two techniques to do this procedure:
either with angled scissors through the antero-
medial portal or with an inversion of optics and
With the first technique, we must be careful not to
leave a too big stump on the anterior segment; the
antero-medial portal is not easy. With the second
technique, the optics is placed through the antero-
medial portal and the instrument, and a rongeur Fig. 4
through the antero-lateral portal. ThisTh method
enables a direct access of the anterior segment by
the rongeur or scissors. – Diffi
fficulties of reduction exist with the aging
(d) Remove the bucket handle with a forceps. bucket handles. We must insist in doing little
The forceps grasps the meniscus fragment at the
Th flexion extension movements associated with a
level of the anterior segment. A soft tear is enough valgus strain while straining the top of the han-
to break the posterior bridge. dle with a more rigid palpater or sometimes the
Some problems can occur: mossy arthro trocar.
Arthroscopic meniscectomy 115

– In case of an impossibility of reduction, it enables tion is done by a rongeur introduced by the antero-
to cut the posterior segment of the medial menis- medial portal, the optics being antero-lateral. Th
cus with a fine rongeur or a curved meniscotome part of the posterior segment is often narrow,
introduced by the antero-medial portal. This ges- the passage of the rongeur is delicate, and a val-
ture is diffi
fficult and requires to take very cautious gus strain must be applied to open this compart-
measures in the process not to damage the pos- ment. The condyle cartilage lesion must be avoided
terior cruciate ligament. by opening up the rongeur. A small-sized rongeur
– The loss of the meniscal fragment may occur. It with upper concavity curve is used at its best.
must be avoided if what has been described previ- (c) Medial flap displaced under the meniscus
ously is respected. The most annoying is the going The flap base is located in the anterior segment or
back of the posterior segment if the anterior seg- medial of the meniscus. The palpater introduced
ment is removed first. Otherwise, we must look through the antero-medial portal extracts this lesion
for the flap to be dislocated at the front with the (Pictures 8 and 9). We can switch the instruments
palpater at the rear of the medial condyle. Then,
Th and optics in the diff
fferent portals. The arthroscope
it will be fixed on a forceps introduced by a second is introduced through the antero-medial portal and
antero-medial portal performed outside the fi first the instruments through the antero-lateral portal.
one. To avoid the lost of the fragment, a second The rongeur starts the meniscectomy at the base
antero-medial portal may be done. Meanwhile, of the flap on the anterior or medial segment. Its
some artifi fices are possible, such as the passage access is direct. The meniscectomy is then per-
of a suture thread by the antero-medial portal, formed to the posterior segment with the rongeur
which will permit the tear and even the extrac- introduced through the antero-medial portal. Th The
tion of the bucket handle after the section of the flap is extracted and the meniscus regulated.
posterior segment (16).
The procedure finishes with a neat checking of the
meniscus remnant by the palpater and a regulariza-
tion with a rongeur. In case of a longitudinal lesion,
lesion of type 3 of Trillat, the principle is identical.

Meniscus flap
Meniscus flaps are resected, and the meniscus is
regularized according to the lesion spread.
(a) Postero-medial flap with medial base (Fig. 5)
The flap resection is made by introducing a ron-
geur through antero-medial portal, the optics
being antero-laterally located. The regularization is
spread as far as the posterior segment. The rongeur
is placed uphill from the lesion. The
Th flap is extracted Fig. 6
either by the forceps or directly by the rongeur. Th The
meniscus remnant is carefully checked.
(b) Postero medial flap with posterior base (Fig. 6)
This type of flap is diffi
fficult to extract since it dislo-
cates back to the posterior segment. The regulariza-

Fig. 5 Picture 8 – Medial flap displaced under the meniscus.

116 The Traumatic Knee

this posterior segment raises occasional problems

with locked knees, and a manual postero-medial
pressure by the assistant enables the posterior seg-
ment to go into the medial compartment. This Th arti-
fice is often useful on degenerative meniscus.
Therefore, the lesion is totally removed. Sometimes
it is useful to do this one-part meniscectomy in two
parts. Indeed, to have a better visibility of the pos-
terior segment, the anterior segment is split off ff by
a transverse incision at the level of the medial seg-
ment. The anterior fragment is removed first.
Three-portal techniques
This technique, commonly used by J.L. Prudhon
enables to perform a “one-part” meniscectomy in
front of any type of medial meniscus lesion. It per-
mits to maintain under strain the meniscus frag-
ment during the whole meniscectomy.
With this technique, it is compulsory to use the
Picture 9 – The palpater introduced through the antero-medial portal median portal of Gillquist (17) for the arthroscope
extracts this lesion. in «the one-part meniscectomy». A third portal can
also be used for the treatment of a bucket handle or
Tear lesion a longitudinal lesion.
Horizontal tear of the medial meniscus requires a
One-part meniscectomy
large excision, named “regulated meniscectomy or
Three main steps are necessary:
one part-meniscectomy.” This meniscectomy can be
(a) Section of the anterior strip (Fig. 7)
performed successfully by a two-portal technique.
The optics is in median situation, through the patellar
It can assess the quantity of the removed meniscus
tendon 1 cm below the top of the patella. A first
fi ante-
ro-medial instrumental portal is carried out above the
(a) Incision in the anterior segment
anterior meniscus segment. The section of the free
This incision is directly made by bistouri through
edge of the meniscus is performed with a 11 mm bis-
the antero-medial portal, the arthroscope located
touri or with a 60° angled scissor introduced through
in antero-lateral. This incision goes the farthest to
the antero-medial portal, and this section is carried
the medial and posterior segment with a tenotome
on as long as obtaining a 1/2-cm meniscus fl flap.
or a rongeur introduced through the antero-medial
(b) Section of the medial segment (Fig. 8)
portal. Th
This anterior section can also be made with a
A second antero-lateral instrumental portal is carried
rongeur introduced through the antero-lateral por-
out, lower than the arthroscopic medial portal. A for-
tal while the arthroscope is into the antero-medial
ceps is introduced through this portal and draws the
portal and displays the anterior segment.
meniscus flap previously detached. A 3 mm menisco-
(b) Section of the medial segment
tome is introduced through the antero-medial portal
This section is performed either through the antero-
Th and goes progressively into the diedre of: (Picture 10)
medial portal with angled scissors or a bistouri or
through the antero-lateral portal with a rongeur.
The palpater enables to check the anterior section
and, above all, to move the flap to assess the size of
the base on the posterior segment.
(c) Section of the posterior segment
The rongeur is introduced through the antero-me-
dial portal, with a valgus strain, the section being
made at the flap base. The section is performed to
the medial segment. A little tractus must be left not
to lose the meniscus fragment.
(d) Extraction of the meniscus
The forceps introduced through the antero-medial
portal grasps the meniscus fragment through its
anterior segment. The posterior tractus splits off ff
under the traction. The meniscus remnant is checked
out and regulated with a rongeur. The regulation of Fig. 7 – Section of the anterior strip.
Arthroscopic meniscectomy 117

Fig. 9 – Section of the posterior strip.

Fig. 8 – Section of medial segment with meniscotome, through the antero-

medial portal, and the forceps draws the anterior segment by the antero-
lateral portal.

Fig. 10 – Removing the meniscus flap.

totally removed (Fig. 10). The meniscectomy is

completed on demand with the rongeur.
Bucket handle and longitudinal lesion
We have previously seen in the treatment of the
bucket handle and longitudinal lesions that there
was a risk to lose the meniscus flap by the two-
portal technique. Thus, we absolutely can carry
Picture 10 – A 3 mm meniscotome is introduced through the antero-me- out a third portal to give a strain to the meniscus
dial portal and goes progressively into the diedre of : inside the detached flap. With this technique, it is not compulsory to
meniscus segment and outside the meniscus wall. carry out a patellar tendon portal but a classical
arthroscopic antero-lateral portal.
– inside the detached meniscus segment; The meniscectomy procedure includes the following:
– outside the meniscus wall. (a) Reduction of the meniscus lesion with the pal-
This progression is carried on as far as the angle pater hook
postero-medial point, and then backward the The arthroscope is introduced through the antero-
medial condyle. lateral portal. The palpater is introduced through
The meniscus segment detached in such a way the antero-medial portal.
can then be dislocated in the intercondyle notch. (b) Section of the posterior strip at the level of the
This is the guarantee of the total section of medial posterior segment
strips of the meniscus. This procedure is performed through an antero-
(c) Section of the posterial strip (Fig. 9) medial portal, with a rongeur, a bistouri, or a teno-
It is easy if the segment is dislocated. Th The for- tome, while leaving a small-size posterior strip.
ceps introduced through the antero-lateral portal (c) Section of the anterior strip
strongly draws the meniscus while the menisco- This procedure is performed through the antero-
tome cuts the posterior strip. The
Th meniscotome is medial portal with angled scissors, or through
introduced through the antero-medial portal and the antero-lateral portal with a rongeur. ThThen, we
the optics through the medial portal. carry out a closer and lower portal to the patellar
Sometimes a rongeur can be used to help this pro- tendon through a meniscotome, or a rongeur can
cedure. By this technique, the meniscus lesion is be introduced.
118 The Traumatic Knee

(d) Extraction of a bucket handle with a forceps

and a complete posterior section
The forceps grasps the meniscus flap at the level
of the anterior segment. Th This forceps is introduced
through the medial portal closest to the patellar
tendon. A soft traction strains the meniscus frag-
ment, while the meniscotome or the rongeur com-
pletes the posterior section. These
Th latter tools are
introduced through the portal closest to the patel-
lar tendon.
With this technique, we can cut the anterior seg-
ment before the posterior segment since the latter
will be handled by a forceps.
The procedure ends by a careful checking of the
meniscus remnant with the palpater and a regula-
tion with the rongeur. In the case of a longitudi-
nal lesion, Trillat type 3 lesion, the principle is the

Picture 11 – medial portal for lateral meniscus tear in cabot position.

Lateral meniscectomies related to skin plans, which considerably hampers

the tool introduction. To avoid this phenomenon,
The lateral meniscus shows anatomic particular- it is appropriate to make the portal in the Cabot
ities different from those of the medial menis- position, which enables to have a direct access to
cus. The accessibility of the anterior segment the lateral compartment.
is often difficult. Its thickness is more impor- The common technique uses the antero-lateral
tant and can raise some problems of section. portal for the arthroscope and the antero-medial
The existence of the popliteus tendon and its portal as a tool portal. The gestures on the antero-
hiatus makes this meniscus more fragile, and lateral meniscus can be also carried out by using
the meniscectomy must preserve the meniscus the medial portal for the arthroscope and the ante-
bridge at the utmost in front of the hiatus, not ro-lateral for the tools to reach the posterior seg-
to transform a partial meniscectomy in a total ment of the lateral meniscus. We should not hesi-
one. In case of the break of the meniscus bridge, tate in changing the tool and arthroscopic portals
the posterior segment is too much unsteady to to improve the vision conditions on the one hand
be kept. but also the ergonomic placement of the tools on
The lateral meniscus presents anatomic variations the other hand.
(discoid meniscus) and may need a meniscectomy.
In addition, it is the core of cystic formations,
which are in fact pseudocyst meniscus more often
related to longitudinal fi
fissure meniscus injuries or Bucket handle, longitudinal injuries (Picture 12)
across clivages.
In case of dislocated bucket handle, it is compul-
sory to reduce the lesion.
Portals – The reduction (Fig. 11) is performed with a pal-
pater hook introduced through the antero-me-
Two portals are usually sufficient
ffi to perform a dial portal. Th
The latter is sometimes diffifficult and
lateral meniscectomy. Th The antero-lateral portal is requires the mobilization of the joint in flexion
fficient to explore the whole meniscus from its with a varus strain to open the lateral compart-
anterior segment to its posterior segment. It will ment.
be carried out in the same way as in the medial – The section of the posterior strip is performed
meniscectomy. through the medial portal with scissors or forceps
The antero-medial portal is generally located (Fig. 12), the optics being in antero-lateral posi-
higher to treat a medial meniscus lesion. It will be tion. Sometimes, it is necessary to go through
done by trans-illumination that avoids injuring a the lateral portal (Fig. 13) if the longitudinal fis-
superfificial vascular element. sure is in the most posterior part of the posterior
The Cabot position (Picture 11) or the simple varus segment.
position and medial rotation slide the patellar plans A small posterior bridge will be kept.
Arthroscopic meniscectomy 119

Picture 12 – Bucket handle of lateral meniscus. Fig. 12 – Section of the posterior strip through the medial portal.

Fig. 11 – Reduction of the bucket handle.

– The section of the anterior strip (Fig. 13) is also

Fig. 13 – Section of the anterior strip.
performed either with a rongeur or a bistouri
introduced through the medial portal or with 90°
angled scissors introduced through the lateral
portal. Th
The meniscus section must be neat and
must grasp the whole lesion at once, to avoid a
flap being left on the anterior segment, which is
more diffi
fficult to regulate when the bucket handle
is removed.
– The lesion extraction (Fig. 14) is carried out
with a forceps introduced through the medial
portal. The meniscus is regulated with a ron-
geur, and the meniscus remnant is palpated
with care.
Sometimes the lateral bucket handle is hard to be
treated, even with an impossibility to reduce the
lesion. Then, the bucket handle must be cut in site.
Therefore, a third portal can be useful to hold the
fragment. While cutting the bucket handle in site,
care should be taken not to damage the anterior
cruciate ligament. Fig. 14 – Extraction of the lesion with the forceps.
120 The Traumatic Knee

lateral portal for the posterior segment and fi first

Radial lesions medial portal for the anterior and median seg-
They are frequent in the median segment. The ments.
regulation through the antero-medial portal is It is sometimes diffi
fficult to reach one of the two
easy since the tool is opposite the lesion. Th The leaves on the anterior segment or at the junc-
regulation is carried out from part to part of the tion. Thus, the 90° angled rongeurs are useful;
lesion. It is performed with a rongeur by split- they are introduced through the medial portal
ting up. The free side must be regular at the end (Picture 14). The shaver can be helpful to treat
of the surgery. We must take care to respect the the anterior lesions by using a curved blade or a
meniscus bridge in front of the popliteus hiatus right blade.
(Picture 13).

Picture 14 – treatment of an anterior lesion of lateral meniscus with the

90°angled rongeur.
Picture 13 – lateral meniscus and respect of the popliteus hiatus.

Cyst of the lateral meniscus (Figs. 15–18)

Meniscus strips
The therapeutics of lateral meniscus cysts has
Th pedicle of the strip is cut off
The ff, and the free side
deeply evolved, from Phemister (18), who was
regulated to avoid any step. The danger is to lose
practicing a total medial meniscectomy through
the strip when cutting it. The use of a rongeur as
arthrotomy, to Muddu (19), who proposed the
a forceps is ever possible with small strips; oth-
treatment by corticoid infi filtration. Chassaing
erwise, a thin tractus must be left, which will be
(20,21) proposes to treat the cyst by arthroscopy.
tracted with a proper forceps. The
Th tools are more
Parisien (22) as well uses the shaver to perform the
often introduced through the antero-medial por-
cyst intra-joint debridement.
tal. If the strip has its base on the posterior seg-
The aim of arthroscopy is, on the one hand, to treat
ment, the antero-lateral instrumental portal is
the meniscus lesion by respecting the meniscus
very interesting.
wall and, on the other hand, to treat the excision
of the cyst content.
Horizontal clivage The arthroscopy has enabled to limit the impor-
tance of the meniscectomy, and the latter is partial
This kind of lesions often spread from the anterior while maintaining a maximum of sane tissue and,
segment to the posterior segment. The Th first step above all, the meniscus bridge en regard of the hia-
of the treatment is to palpate the whole lesion to tus popliteus.
assess its spread and, above all, its relation with The surgery starts by the treatment of the menis-
the hiatus popliteus. cus lesion by respecting the meniscus wall. For
The regulation is more often carried out through a some people, the treatment stops there; the cyst
splitting up with a rongeur alternating the portals: is cured when the meniscus lesion is treated. Then,
Arthroscopic meniscectomy 121

Fig. 15
Fig. 16

Fig. 17 Fig. 18

the notch opposite the cyst is opened with a ron- a splitting up with a rongeur is very efficient
ffi but
geur or with a meniscotome (23). laborious. The procedure starts from the axial
The last step of the surgery is the exeresis of the side often thick, diffi
fficult to split up, and getting
cyst content. At best, it is removed by using a away under the rongeur. Thus, we must go from
motorized blade or «shaver» introduced through the antero-medial to the antero-lateral portal, to
the meniscus communication of the cyst. The Th reach the free side in the best conditions. ThThe ron-
shaver sweeping inside the cyst will sharpen the geur introduced through the lateral portal begins
cyst walls and raises a bleeding improving the
cicatrization. The angled shaver is useful when the
perforation is located in the anterior segment or at
the junction of the anterior and median segments.
Hulet and Locker (24,25) point out that the recidi-
vation of the cyst is in most of the cases due to an
unsatisfactory treatment of the meniscus lesion.
Persistant meniscus lesion of the anterior seg-
ment. According to him, the use of angled instru-
ments and the change of portal are imperative to
leave no lesion.

Discoid meniscus (Picture 15)

Th type of meniscus can be at the origin of
a painful lateral syndrome, above all, when it
cracks. The partial meniscectomy or «menisco-
plasty» is sometimes very difficult,
ffi and a subto-
tal meniscectomy is often necessary. A meniscus
with a proper shape must be reshaped. Therefore,
Th Picture 15 – discoid meniscus.
122 The Traumatic Knee

the meniscoplasty on the posterior segment. We Physiotherapy is systematically proposed, and

continue in the median segment far from the some physiotherapy sessions sound to be profit-
meniscus wall. Later we can change arthroscope able. Physiotherapy must be soft and unpainful.
and tools to cut the anterior part of the meniscus For this goal, a precise protocole must be given
with the rongeur introduced through the medial to the physiotherapist. The goal is to recover
portal. At least, we remove the flap, and the rem- the knee mobility without any pain. The work
nants become like a normal meniscus with the of muscular strengthening is carried out with
time (26). a lot of care with the association of systematic
stretching of the anterior and posterior muscu-
lar chains.
At last, we must be pinpoint that the follow-ups of
The follow-ups the lateral meniscectomy are longer and more dif-
ficult than the medial meniscectomy (29).
The arthroscopy ends up with a cautious clean-
ing of the knee. Any meniscus fragments must be
removed off ff, without any remnants in the portal,
sources of chronic pains. The tourniquet is released Conclusion
before the joint draining off;ff this enables to ensure
no intra-joint important bleeding or at the portal The meniscectomy techniques have become daily
levels. procedures of an orthopaedist surgeon. Mean-
The closure of the portals is carried out by several while, these procedures must not be generalized
ways: unresorbable wires, resorbable wires, or even since these procedures require a long learning
adhesive bandage. curve to be correctly performed. The surgery indi-
Some infl flammatory granulomes have been cation must be decided with great care and caution
observed at the entry points. Th These induration since the consequence of a meniscectomy may be
points may come from small meniscus fragments severe with the probability of a long-term arthritis
embedded in the portal. A particularly cautious development.
cleaning must be done a these portals. A good development of a meniscectomy is per-
This surgery is often carried out in ambulatory formed with an accurate surgery indication, and
hospitalization. The procedure can be performed additional proper examinations are asked respect-
under local anesthesia as shown by Béguin and ing the technical principles.
Locker (27,28); nevertheless, the other forms of
anesthesia are more currently carried out: rachi-
anesthesia, crural block and general anaesthesia. References
Patients go out the same day of the surgery. Th The
surgeon must provide information to the patient 1. Watanabe M, Ikeuchi H L’arthroscopie. Encycl Med Chir,
on the surgery and its expected follow-ups. Paris, Appareil locomoteur, 14001:10, 4-1981<AQ: Please
check Refs. 1, 6, and 10 for completeness. Please provide
The surgery report is an important moment. It year of publishing in these refs.>
must be accurate, and precise the amount of the 2. Dobner JJ, Nitz AJ (1982) Post meniscectomy tourniquet
removed meniscus, the remaining part, and the palsy and functionnal sequelae.Am J Sports Med 10:211–
aspect of the meniscus wall. Finally, it is important 214
3. Johnson DS, Stewart H, Hirst P, Harper NJ (2000) Is tour-
to precise whether this meniscectomy has been niquet use necessary for knee arthroscopy. Arthroscopy
fficult, laborious, or easy. This is an indicator for 16:648–651
the evolution and the meniscectomy prognosis. It 4. Thorbald J, Ekstarnd J, Hamberg P, Gillquist J (1985) Mus-
must also give details on the cartilage state with cle rehabilitation after arthroscopic meniscectomy with or
the diff
fferent steps of gravity and the extension of without tourniquet control. A preliminary randomized
study. Am J Sports Med 13:133–135
lesions for a long-term prognosis. The iconogra- 5. Daniel DM, Lumkong G, Stone ML, Pedowitz RA (1995)
phy is an important element: photo or video. Th The Eff
ffects of tourniquet use in anterior cruciate ligament
development of the digital photography and soft- reconstruction. Arthroscopy 11:307–311
ware for filing these photos are interesting data for 6. Orengo P, Zahlaoui J Chirurgie des ménisques. Encycl Med
the clinical file of the patient. Chir, Paris, Techniques chirurgicales, Orthopédie trauma-
tologie, 44785, 4.10.06, 18 p
The walking is possible at once without any help. 7. Blin JL, Tremoulet J, Hardy Ph, et al. (1995) Méniscecto-
Sports activity is possible after 1 month post-sur- mie au laser Holmium:Yag versus méniscectomie méca-
gery in case of no complication and, above all, in nique sous arthroscopie. Etude comparative prospective
the context of a traumatic meniscus lesion. In the randomisée. (Résulats précoces sur 96 sujets) nnales de la
Société Française d’arthroscopie
context of degenerative lesions, sports activity will 8. Chatain F, Robinson Ah, Adeleine P, et al. (2001) The
Th natural
depend above all on the degree of coexistent carti- history of the knee following arthroscopy medial meniscec-
lage lesions. tomy. Knee Surg Sports Traumatol Arthrosc 9:19–27
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9. Folinais D, Thelen Ph (1993) L’imagerie des ménisques des 19. Muddu BN, Barrie JL, Morris MA (1992) Aspiration
genoux après 50 ans. Rev Chir Orthop 79:320–334 and injection for meniscal cysts. J Bone Joint Surg
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dégénératif. Sauramps Médical 10/2000 opératoire dans le traitement du kyste du ménisque
11. Northmore-Ball MD, Dandy DJ (1982) Long term results externe. J Med Lyon 66(1406):449-453
of arthroscopic partial meniscectomy. Clin Orthop 21. Chassaing V (1985) Chirurgie du genou par arthroscopie.
167:34–42 Conf. d’enseignement de la SOFCOT 1985, n 23, pp. 103–
12. Neyret Ph, Walch, Dejour H (1988) La méniscectomie 120. Expansion scientififique Française, Paris
interne intra-murale selon la technique de A. Trillat: résul- 22. Parisien JS (1990) Arthroscopic treatment of cysts of the
tats à long terme de 258 interventions. Rev Chir Orthop menisci. Clin Orthop 252:154–158
74:637–646 23. Glasgow MMS, Allen PW, Blakeway C (1993) Arthroscopic
13. Trillat A (1973) Les lésions méniscales internes. Les treatment of cysts of the lateral méniscus. J Bone Joint
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Lyonnaises de chirurgie du genou. 04/1971. Simep, ed., 24. Hulet C (1993) Les kystes du ménisque externe. Etude
Villeurbanne rétrospective d’une série de 124 kystes traités par arthros-
14. Trillat A (1962) Lésions traumatiques du ménisque interne copie. Thèse Médecine 1993 Caen
du genou, classifi
fication anatomique et diagnostic clinique. 25. Locker B, Hulet C, Vielpeau C (1992) Lésions traumatiques
Rev Chir Orthop 48:551–560 des ménisques du genou.Editions techniques. Encycl Méd
15. Beaufifils P (1993) L’arthroscopie opératoire dans la Chir (Paris, France), Appareil locomoteur, 14084 A10:12
pathologie mécanique du genou. Apport et limites. 26. Vandermeer RD, Cunnigham FK (1989) Arthroscopic
Cahiers d’enseignement de la SOFCOT. Conférences treatment of the discoid lateral meniscus: results of long
d’enseignement, pp. 93–108 terme follow-up. Arhroscopy 5:101–109
16. Binnet Mehmet SMD, Gurkan Ilksen MD, Cetin Cem MD 27. Beguin J, Locker B (1981) Arthroscopie du genou sous
(2000) Arthroscopic resection of bucket-handle tears with anesthésie locale. J Med Lyon 1932:7–9
the help of a suture punch: a simple technique to shorten 28. Locker B, Beguin J, Th
Thomassin G, et al. (1990) L’anesthésie
operating time. Arthroscopy 16(6):665–669 intra-articulaire en arthroscopie du genou. Rev Chir
17. Gillquist J, Oretorp N (1982) Arthroscopic partial menis- Orthop 76(Suppl 1):152–153
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18. Phemister DB (1923) Cysts of th lateral semi-lunar carti- arthroscopie. Encycl Med Chir. Techniques chirurgicales-
lage of the knee. JAMA 80(9):593–595 Orthopédie-traumatologie, 44-765:12
Chapter 11

P. Wilmes, D. Pape, R. Seil Meniscal sutures

Introduction debridement of the bradytrophic meniscus tis-

sue. Especially in isolated meniscal tears, this

iomechanical and clinical trials have demon- is of foremost importance, whereas simultane-
strated the importance of the menisci for the ous ACL reconstructions have a beneficial fi eff
function of the knee. The menisci increase the on meniscus healing, presumably because of the
surface area for femoro-tibial load transmission, aid increased intraarticular concentration of growth
in the mechanics of joint lubrication, and act as sec- factors due to the postoperative hematoma. Tear
ondary stabilizers in anterior cruciate ligament (ACL)- debridement and local synovial, meniscal, and
ficient knees. Thus the focus in the treatment of capsular abrasion are performed with a shaver or
meniscal tears has shifted from systematic removal of fic meniscal rasps to stimulate a proliferative
the menisci toward preservation and repair whenever fibroblastic healing response and remove necrotic
possible. Nonetheless, most investigators estimate tissue. The tear rim should be rasped in order to
that only 10–15% of meniscal tears are reparable, remove necrotic tissue and stimulate bleeding.
usally in association with ACL reconstructions (1,2). Synovial abrasion can induce a similar effffect, espe-
The aim of meniscal repair is to reduce pain and possi- cially with a meniscus lesion situated more than
bly to restore ideal knee function by keeping the origi- 3 mm away from the periphery (zones 2–3). Abra-
nal meniscus. Indications for meniscal repair are: sion should be performed on the femoral and on
– full-thickness, vertical longitudinal tears >10 mm; the tibial side (3). Thus a healing process similar
– partial-thickness unstable vertical longitudinal to the one known from other connective tissues
tears (generally in tears >10 mm); is induced (4).
– location at the meniscosynovial junction or in the A further possibility that has been mentioned in
vascularized red-red and red-white zones (less than the literature to stimulate the healing process after
3 mm away from the meniscosynovial junction); meniscal repair is meniscal trephination. Using an
– little secondary meniscal degeneration. 18-gauge spinal needle to penetrate the peripheral
Previous studies have shown improved results with meniscus to the synovium (needling), bleeding and
concomitant ACL reconstructions, peripheral lesions revascularization might be stimulated (5,6).
(rim width <4 mm), repair within 8 weeks of injury When isolated tears are to be repaired, addition
and tear length of less than 2 cm. The Th ideal candi- of a fibrin clott has been considered. Using veni-
date for meniscal repair is the active, young patient, puncture, an aliquot of 5–10 mL of whole blood is
although no general upper age limit has been defined.
fi obtained, and then a fibrin clot is prepared using
In patients over 40, meniscal repair is worth consid- a frosted glass stirring rod. Th
The clot can be intro-
ering, depending on tear morphology and tissue duced arthroscopically into the meniscal tear (7).
quality, whereas in children, meniscal repair should
always be considered as the standard procedure.
Preoperative patient information must include the Outside-to-inside technique
necessity for long and intensive rehabilitation as well
as absence from pivoting sports for about 6 months. This technique is most appropriate for tears located
in the middle and anterior aspects of either menis-
cus (Fig. 1). Two spinal needles are inserted from
Surgical technique outside through the skin into the joint, perforat-
ing the meniscal basis and the central meniscus
fragment. Through a first needle, a suture loop is
Healing enhancement introduced. A second suture is introduced through
the posterior needle. It is grasped with a specific
After arthroscopic identification
fi and evaluation instrument and drawn through the suture loop
of the meniscal tear, it is necessary to perform a into the ventral needle. By drawing the loop back,
126 The Traumatic Knee

Fig. 1 – Outside-to-inside technique: (A) punction with filled cannulas, (B)

horizontal mattress suture. (From Ref. 8.)

the free end of the posterior suture is brought to

the outside. Both suture ends can then be tied
together over the capsule. This
Th technique has the
advantage over inside-to-outside sutures that it
can be performed percutaneously and that it does
not require large skin incisions. Furthermore, it Fig. 2 – Inside-to-outside technique: (A) abrasion, (B) positioning of the
is very cheap, is technically easy to perform, and first cannula, (C) control of knot and suture. (From Ref. 8.)
does not require any specific
fi instruments.

All-inside technique
Inside-to-outside technique
Originally, the fi
first all-inside meniscal suture tech-
A very popular technique for meniscal repair is the nique has been described by Morgan et al. These
repair from inside to outside (Fig. 2). It is especially authors used the posterior capsular space to enter
recommended for posterior horn repairs. It requires a specifi
fic suture passer through either a postero-
fic instruments: single or double cannulas and lateral or a posteromedial approach, especially for
sutures provided with long and fl flexible needles. lesions located at the meniscosynovial junction (9).
The cannulas are positioned under arthroscopic As an alternative to improve repairs of the menis-
view from the anterior portals at the tear site. TheTh cus tissue in the area of the posterior horn, spe-
needles are directed through these cannulas into cifi
fic all-inside meniscus fixation techniques and
the meniscus substance. An accessory longitudi- devices have been developed at the beginning of
nal, posteromedial, or posterolateral incision must the 1990s. These techniques were designed to be
be performed to identify and retract the needles. easy to use and to lower the potential risk of inju-
After soft-tissue preparation to the capsule, a soft- ries to the neurovascular structures. The implants
tissue retractor provides the necessary protection diff
ffer in shape (barbed arrows, with or without
for the neurovascular structures when the needles arrowheads; screws; staples) and material (biode-
and suture material are passed from the intraar- gradable, nonabsorbable) (Fig. 3).
ticular space through the meniscus and capsule to In order to decrease their potential risk of carti-
the outside. At the end of the procedure, the suture lage injuries (10,11), some implants such as the
ends are tied over the capsule. ContourTM Meniscus ArrowTM (Conmed Linvatec,
Meniscal sutures 127

Fig. 3 – All-inside meniscal repair devices, from left to right: FasT-FixxTM (Smith & Nephew), H-FixxTM (Mitek), Meniscal DartTM (Arthrex), Meniscal
StaplerrTM (Arthrotek), BioStingerrTM (Linvatec), Meniscus Arrow
wTM (Linvatec), Clearfix Screw
wTM (Mitek), SD Sorb StapleeTM (Surgical Dynamics).

Largo, FL, USA) have been improved over the One of the latest all-inside devices is the Meniscal
years to lower the profile
fi of the part of the implant CinchTM (Arthrex, Inc., Naples, FL, USA), intro-
lying on the surface of the meniscus (12). Despite duced in 2008. Designed to be used through a low
these improvements, these implants should not be arthroscopic portal, near the surface of the tibia,
used to repair centrally located tears (zone 3). Bio- it allows an all-inside repair without intraarticu-
mechanical trials revealed comparable results to lar knot-tying, similar to the FasT-FixTM (Smith
meniscal sutures (13–15). Some authors combine & Nephew, Inc., Memphis, TN, USA). Clinical
repair with devices and standard meniscal sutures, follow-up studies will show its place amongst the
using the implants only to complete the repair established devices.
close to the insertion area of the posterior horn
(16). It is recommended to place the implants with
intervals of 5 mm. The use of endosopic meniscal
repair devices is not recommended in unstable Biomechanical evaluation of meniscal repair
knees, in the anterior horn area, in chronic dis- Biomechanical testing is intended to evaluate and
located bucket handle tears, and in tears near the to improve the mechanical factors of meniscus
meniscosynovial junction (zones 0–1) and near the healing, either for meniscus sutures or for new
popliteal gap. They should be used with an appro- meniscal repair devices. In order to be as close
priate length because, if they are too long, they can as possible to the clinical setting, biomechanical
cause irritations at the capsule or even in the sub- studies have been performed under different
ff con-
cutaneous tissue. ditions, each of them simulating a specific fi period
Some of the above-mentioned relative contraindi- after meniscal repair:
cations have been overcome with the development 1. Immediately after repair (tt = 0): so-called time-
of hybrid repair techniques such as the currently zero cadaver studies.
very popular FasT-FixTM (Smith & Nephew, Inc., 2. During the healing period (tt = 0–12 weeks): such
Memphis, TN, USA), which combines the presence studies have been performed either as tissue-
of an implant with a suture (17–23) or devices culture models or as animal experiments.
designed to facilitate all-inside sutures such as the 3. After the initial healing phase (tt > 12 weeks). So
Meniscal ViperTM (Arthrex, Inc., Naples, FL, USA) far, the biomechanical properties of meniscus
(Fig. 4), even if for the latter the surgeon should be repair at this period have only been addressed in
familiar with arthroscopic knot-tying (24,25). animal studies.
These instruments allow for arthroscopic repair of
a meniscal tear from anterior portals and can be
used in areas such as the popliteal space at the pos- Time-zero studies
terior horn of the lateral meniscus where the use of
an inside-out technique or repair with an implant Most of the studies dealing with laboratory testing
is either diffi
fficult or not recommended. of meniscus repair have been performed as time-
128 The Traumatic Knee

zero studies, testing the tensile fixation strength In later biomechanical studies, many variables
(TFS) of either sutures or sutures compared to fi fix- infl
fluencing the TFS of meniscus sutures or
ation devices (13,14,26,27,28,29,30,31,32,33,34,3 repair devices could be identified.
fi These variables
5,36,37,38,39,40,41,42,43) (Arnoczky et al. 2001, included the nature of the tested menisci (animal
Kohn et al. 1989). (until today bovine and porcine menisci have been
In the first laboratory study on meniscus repair, used) vs. human origin; young vs. old specimen),
Kohn and Siebert (44) described the two basic the suture strength, the insertion angle of repair
principles of meniscus repair biomechan- devices, their design (form of head, barbs, etc.),
ics. The authors compared open meniscus repair their mechanical properties such as thickness and
techniques to arthroscopic techniques. They found elasticity, etc. Furthermore, biomechanical testing
that the circumferentially oriented horizontal col- varied from study to study since there is no con-
lagen fiber bundles were responsible for the higher sensus regarding the exact testing conditions. Th
TFS for vertical sutures compared to horizontal might explain the large variations encountered
sutures. They further showed the importance of with some repair devices in different
ff studies and
the superfi
ficial, dense layer of thin collagen fibrils, makes a comparison of the TFS between dif-
which increased the TFS of mattress sutures com- ferent studies extremely difficult
ffi .
pared to sutures including only deeper layers of In several studies, the TFS of some of the devices
collagen bundles. approached the TFS of sutures. However, the

Fig. 4 – All-inside repair with the Meniscal ViperrTM device (Arthrex, Inc., Naples, FL, USA): (A) tear identification with a
probe, (B) introduction of the device, (C) perforation of the meniscus for suture placement, (D) placement of the suture
material, (E) cutting of the excess suture material with a special knot cutter, (F) final result with all-inside suture.

Fig. 5 – (A) Meniscal CinchTM (Arthrex, Inc., Naples, FL, USA). (B) Principle of all-inside repair with the CinchTM.
Meniscal sutures 129

Fig. 6 – The main parameter that has been used in these stud-
ies was the tensile fixation strength (TFS) and, in more recent
publications, also the linear stiffness of a single suture or a menis-
cal repair device. The fixation strength has always been analyzed
on a materials testing machine. After creating an artificial tear in
either human or animal menisci, a uniaxial load is applied to the
repaired meniscus in an axis parallel to the long axis of the suture
or the implant to be tested. The ultimate tensile load is recorded
on a load-displacement curve.

sutures still have to be considered as the gold stan- Table 1 – Animal studies investigating the tensile failure strength of
dard of meniscus repair. repaired menisci.
Animal Time after Tensile failure
model surgery strength
Biomechanics of the repair during the early healing (months)
phase Ref. 48 Goat 4 30% of normal
Two mechanical factors have been analyzed dur- Ref. 49 Dog 3 Up to 80% of
ing this phase: the evolution of TFS of the sutures/ normal tissue
devices over time (45) (Arnoczky et al. 2001) and Roeddecker Rabbit 3 Fibrin glue: 42%
the eff
ffect of repetitive loading on meniscus repairs K, 1994Ref. Suture: 26%
(40,42,46). 50 No therapy: 19%
The effffect of hydrolysis time on sutures/devices Ref. 51 Dog 12 SD staple > suture
has been analyzed in a tissue culture model. In Ref. 52 Goat 1,5 <50% of normal
these studies, the menisci were incubated after tissue
the repair over a defi fined period, after which the
Ref. 53 Dog 6 50% of normal
TFS were evaluated. Using PDS sutures, Dienst et
al. (45) found a significant
fi decrease in the TFS of
nearly 50% after 6 weeks, whereas the TFS of non-
months of up to 80% of the intact control menis-
absorbable suture material did not change. Arnoc-
cus in dogs, the other authors found data that were
zky and Lavagnino (47) found no decrease in TFS
far from normal. This shows that meniscal scar tis-
for the BioStingerTM, the Meniscus ArrowTM, and
sue does not reach its initial biomechanical prop-
the Clearfifix ScrewTM (Mitek Products Inc., A Divi-
erties after a period of 3–4 months. Koukoubis et
sion of Ethicon, Inc., Westwood, MA, USA) over a
al. (51) observed an increase in TFS of repaired dog
period of 24 weeks. However, the SD stapleTM (Sur-
menisci over a 1-year period. In a recent biomechni-
gical Dynamics, Inc., Norwalk, CT, USA) and the
cal trial in dogs, Cook et al. (53) studied the effects
Mitek Meniscal Repair SystemTM (Mitek Products
of introducing a bioabsorbable conduit into avascu-
Inc., A Division of Ethicon, Inc., Westwood, MA,
lar meniscal tears. Functional healing with bridging
USA) showed a complete loss of fixation strength
tissue and biomechanical integrity were noted in
after 24 and 12 weeks, respectively.
71% of avascular meniscal defects 6 months after
Repetitive, cyclic loading of meniscus sutures
surgery. The tissue revealed a failure strength at
showed the appearance of a gap between the two
6 months of 50% compared to normal tissue.
parts of the meniscus (40), even with low loads of
only 10 N (36). Gapping was most important with
the commonly used PDS 2-0 sutures. Cyclic testing Forces acting in vivo
led to failure of sutures and new devices. ThThe fail- In vitro testing of meniscus repair has been per-
ure of the devices was inversely related to the size formed with tensile forces only. ThThe tensile forces
of their head (14). acting on meniscal repairs in vivo are unknown.
Furthermore, there are not only tensile but also
compressive and shear forces acting on the menis-
Biomechanics of the repair during the late healing phase cus. These complex forces are diffi
fficult to reproduce
in vitro. Only few studies tried to analyze this
During this phase, laboratory testing of meniscus question. Kirsch and Kohn investigated the tensile
repair is essentially performed in animal studies forces acting on posterior horn sutures of the medial
analyzing the failure strength of the scar tissue meniscus in a cadaver model. They were lower
(Table 1). Even if Kawai (49) found TFS after 3 than expected, as they never exceeded 10 N (54).
130 The Traumatic Knee

Dürselen et al. (34) studied the eff ffect of cyclic joint ing from a horizontal suture technique. The
Th results
loads on the initial fixation strength of diff fferent from their investigation, however, did not support
meniscal repair techniques. Th Three diff
fferent menis- their hypothesis, as horizontal sutures were found
cal refi
fixation implants and one suturing technique to be superior to vertical suture techniques. They
(Meniscal FastenerTM, Meniscal ArrowTM, ClearFix concluded that meniscal repair with horizontal
ScrewTM, and a horizontal suture [PDS 1]) were suture techniques can withstand elongation due to
tested for initial stability in porcine knee joints after shear forces more eff
ffectively than can vertical mat-
cyclic joint loading. Whereas the horizontal suture tress sutures.
showed the highest pullout force (103 N, SD 19 N),
the Meniscal ArrowTM (52 N, SD 18 N), the Menis-
cal FastenerTM (29 N, SD 3 N), and the Meniscal
ScrewTM (22 N, SD 8 N) failed at signifi ficantly lower The biological healing factors
loads; cyclic loading led to a decreased initial pull- of meniscus repair
out force only for the horizontal suture (82 N, SD
26 N) and the Meniscal FastenerTM (23 N, SD 5N). As early as in 1936, King wrote that for a menis-
It was concluded that cyclic joint loading can lead cal tear to heal, the torn meniscus must commu-
to reduced fixation strength, especially of menis- nicate with its peripheral blood supply. Arnoczky
cal refi
fixation implants and sutures with relatively and Warren described the vascularization of the
low stiffffness. Uncertainty remains as to which fixa- meniscus in 1982, showing that the inferior and
tion strength is necessary to provide conditions for superior medial and lateral geniculate arteries
meniscal healing. Many meniscal fixation
fi implants give rise to a perimeniscal capillary plexus enter-
have low pullout forces, yet it is still unknown if ing the outer 10–30% of the meniscus tissue.
these forces are higher than the forces the implants Furthermore, they found that a vascular synovial
must resist in vivo. Therefore, it was hypothesized tissue (synovial fringe) extends over the menis-
by Dürselen et al. (55) that meniscal repair with the cal rim and contributes markedly to the repara-
meniscal screw as an example for a device of low tive response. Recently, Bray et al. found a fast
pullout force signifi ficantly reduces tear gapping. and prolonged increase in meniscal vascularity in
The authors set longitudinal tears in the posterior
Th a rabbit model after injury, showing that there is
horn of the medial menisci of porcine knee joints, a vascular response of the meniscus to a traumatic
then the knees were moved in a loading and motion event (58,59). In 1992, Arnoczky et al. classifi fied
simulator under various external moments and the meniscus tissue into three diff fferent healing
axial loads, and gapping of the tear was registered. zones according to the degree of vascularization of
The measurements were repeated after fixation
Th the injured meniscal region. Th The well-vascularised
of the tears with three ClearFix ScrewsTM, which periphery of the meniscus was defi fined as the “red-
show a low pullout force of 20 N only; maximum red zone” because both sides of a tear in this area
gapping (median 1.6 mm, min/max 1.1/1.8 mm) appear to be red under arthroscopic control. On
occurred at 200-N axial joint load under the combi- the opposite, the central, non-vascularized region
nation of a valgus and external rotation moment. of the meniscus was called “white-white zone” and
Fixation with the ClearFix ScrewTM signifi ficantly the area in between, the “red-white zone”. In the
reduced tear gapping in all load cases, and moder- latter the peripheral side of the tear appears to be
ate joint loads only led to small gaps of meniscal red under arthroscopy, whereas the central side
tears. Meniscal fixation with the ClearFix ScrewTM appears white. Grossly each zone corresponds to a
prevents longitudinal meniscal tears from gapping. third of the width of the meniscus. Corresponding
This could indicate from a biomechanical point of to this classifi
fication, a good healing capacity has
view that fixation implants of low pullout strength been observed in the red-red zone (60), whereas no
are not in danger of failure in a normal rehabilita- healing or only a very low healing response can be
tion regimen. Studying the distraction forces on expected in the central zone (61).
repaired meniscus bucket-handle lesions, Becker The healing process of the meniscus basically does
et al. (56) found data suggesting that distraction not diff
ffer from the classic wound healing pathway,
forces are not the primary factor in the mechani- which is differentiated
ff into an infl
flammatory phase, a
cal stability of meniscal repair. They assumed that granulation phase with the formation of a fi fibroblastic
other factors such as shear forces are of greater sig- scar and vascular ingrowth, and finally the ingrowth
ficance. Zantop et al. (57) designed a shear force of undiff
fferentiated mesenchymal stem cells.
scenario for evaluation of biomechanical proper- In order to allow for increased meniscal preserva-
ties of meniscal sutures, hypothesizing that menis- tion in the future, it is necessary to identify poten-
cal repair using a vertical suture technique would tial ways to improve meniscal healing in general and
result in signifi ficantly less elongation when sub- healing in the avascular area in particular. Recent
jected to a cyclic loading protocol than that result- eff
fforts have been made to understand meniscal
Meniscal sutures 131

healing on a cellular basis. Verdonk et al. character- tion regime depending on the repair of a medial
ized the meniscus cell phenotypes and found that or a lateral meniscus. Non-pivoting sports such as
the meniscus was populated by diff fferent cell types cycling or jogging can be started at 3 months. If
(62). Several studies showed that meniscal cells of the patient experiences knee pain or swelling, such
all zones have the potential to participate in the eff
fforts should be postponed. Return to pivoting
reparative response. Bhargava et al. (63) showed sports can usually be considered after 6 months.
fic growth factors (PDGF and HGF) were
that specifi
able to stimulate the migration of cells from all
zones of bovine menisci. Tumia et al. (64) found
that BFGF stimulated cell proliferation and extra- Complications
cellular matrix formation from all zones of bovine
menisci. Kambic et al. (65) and Lin et al. (66) ana- According to Small (69), the complication rate
lyzed the expression of smooth muscle actin (SMA), after meniscal sutures amounts to 2.6%. ThThe most
a wound-healing protein in human and canine common complication after arthroscopic suture
menisci. They found an SMA production in the of a medial meniscus is a lesion of the saphenous
meniscal tissue, expression which differed
ff accord- nerve. The frequency of this complication can be
ing to the depth of the cell layers and showed that up to 12.9% of inside-out sutures of the medial
meniscal cells have the capacity to contribute to meniscus (70–78). TheTh lesion of the main nerve
wound contraction. In a study on rabbit meniscal induces numbness, paresthesias, or pain in the
tears, Becker et al. (67) found an increased expres- innervation area on the inner side of the calf. It
sion of vascular endothelial growth factor at the can result from an intraoperative pressure trauma
periphery and the central zone of the meniscus. or from tying the knot over the nerve. In case of
Despite this, they could not observe any meniscal injury of the infrapatellar branch, running distally
healing in the inner zone. They concluded that the from the incision for the inside-to-outside tech-
central, avascular zone has no intrinsic capacity to nique to the ventral side, the paraesthesia is lim-
induce angiogenesis in the healing process. ited to its innervation area, about 8–10 cm under
These findings show that the meniscus has an intrin- the patella. Most nerve injuries recover within a
sic reparative potential that must not necessarily be few months, and it is rarely necessary to perform
limited to areas with blood supply. Based on such a neurolysis. Kimura et al. (73) described a medial
findings, biologically based therapies might be devel- meniscal cyst after meniscal suture. Th
The structure
oped in the future. In a recent study, such a strategy on the lateral side most frequently at risk is the
has been presented in an animal model. Peretti et al. common peroneal nerve (79).
(68) filled a porcine meniscus tear in the avascular The use of meniscal repair implants can implicate
zone with an allogenic meniscal scaffold
ff seeded with certain specifific problems. Migration of broken
autologous chondrocytes. They observed a complete arrows into the subcutaneous fat tissue (80), for-
healing in these animals, whereas no healing could eign body reactions, prolonged eff ffusion (81) and
be noted in their control groups. chondral lesions on the femoral condyle (11,82,83)
were described.

Postoperative weight-bearing conditions

and rehabilitation Results
Th is no consensus regarding the type of rehabil-
There For evaluation of healing rates, short- and long-
itation after meniscus repair. Individual protocols term results must be taken into consideration. Th
ff with respect to type and length of immobi- analysis of short-term results should evaluate
lization, weight-bearing, and postoperative range anatomical and clinical healing aspects. ThThe ana-
of motion. Most authors prefer to limit the range tomical criteria are classifi
fied into complete heal-
of motion in the first 6 weeks following surgery by ing, incomplete healing, and failed healing (84).
using a brace and allow only touch-down weight- An appropriate evaluation is only possible with a
bearing. Alternatively, full weight-bearing can be second-look arthroscopy or, more recently, with
allowed with the knee in full extension in a brace. arthro-CT scans or arthro-MRI (magnetic reso-
Passive range-of-motion exercises are generally nance imaging). The
Th clinical criteria include the
recommended, usually not exceeding 90° of knee presence or absence of meniscal signs and joint
flexion during the first 6 weeks in order to limit eff
ffusion. By using only clinical criteria for evalu-
the load on the posterior horns and to avoid an ation of healing rates, the results are usually too
excessive stress of the repaired tissue and fixation
fi optimistic. Over 50% of the anatomically incom-
mode. Some authors apply a different
ff rehabilita- plete or failed meniscal sutures are not recognized
132 The Traumatic Knee

clinically (1,85,86). The Th clinical and anatomical Long-term results after meniscal suture can be
healing rates vary between 50% and 91% (87) (Seil evaluated by the following three criteria:
2001). This
Th is related on the one hand to diff ffering – Rerupture rate, which can be determined accord-
evaluation criteria, and on the other hand to the ing to diff
fferent criteria (arthroscopic, clinic,
following factors: MRI)
– Stability of the knee joint, concomitant ACL – Radiologic signs of arthritis, as indirect signs
reconstruction: The best healing rates (ana- for the biomechanical function of the repaired
tomical criteria) were seen in meniscal repairs meniscus
with concomitant ACL reconstruction (86). In – Joint function, evaluated by diff fferent scoring
most of the studies, these rates amounted to systems
over 75%. The healing rates of isolated meniscal
fixations in stable joints were indicated with
50–75%, whereas sutures in unstable joints with- Joint function
out concomitant ACL reconstruction showed the
smallest healing rates with less than 50% (60). The primary goal of meniscal repair is to restore
These data allow the conclusion that a concomi- joint function. With adequate rehabilitation, this
tant ACL reconstruction possibly permits a bet- is achieved in most patients. Considering the
ter meniscus healing. One of the hypotheses to reviewed investigations (60,94–104), normal knee
explain this phenomenon was that the hemar- function is reestablished after meniscal repair in
thros following ligamentoplasty would induce a 71–100% of the patients. Although the comparabil-
“biological healing reaction” (1,3). However, this ity of these results is difficult
ffi from a scientifi
fic point
connection could not be confirmed fi in all of the of view, with diff
fferent scoring systems in use (HSS,
studies (85). OAK, IKDC, Lysholm, Tegner, Cincinnati, SF-36),
– Distance from tear to meniscal base: Because they all tend in the same direction (Table 2). Menis-
of the good vascularization, tears located at the cal repair was commonly performed in stable knees,
meniscal periphery have a better healing process ACL ruptures being surgically treated in most cases
than central tears (61,86). (94,95,97,98,100,101,103,104). Only four authors
– Type and size of tear: Meniscal healing after (60,96,99,102) also report on meniscal sutures
suture is furthermore infl fluenced by the type and under unstable conditions (Table 2).
the size of the tear. It is well known that radial DeHaven et al. (60) found reruptures only in
and complex tears have unfavorable healing rates. unstable joints, either with known ACL tears
Complex and chronically displaced bucket handle that had not been treated or with repaired ACLs.
tears showed lesser healing rates than non-dis- Muellner et al. (99) also report two reruptures out
located longitudinal tears (88). Some authors of three unstable joints with side-to-side differ- ff
found no correlation between meniscal disloca- ences in passive sagittal knee laxity of more than
tions and the failure rate of suture repairs (1,89) 3 mm. Interestingly, Johnson et al. (96), after
(. Cannon and Morgan (90) could demonstrate clinical evaluation of joint function, found a nor-
that the failure rate was proportional to the tear mal knee function in 76% of the cases, while 100%
length (<2 cm: 15%, 2–4 cm: 20%, >4 cm: 59%). of the patients were subjectively satisfied fi with
Valen and Molster (89) confi firmed these results, the surgical outcome. Th The five patients defi fined
whereas other authors found no influence fl of as unsuccessful repairs were also assessed unsta-
these specifi fic factors on healing (1,91,92). ble according to clinical criteria. A comparison
Other factors of infl fluence are the time between with the rerupture rate, however, is not possible
injury and surgery (86,89,91–93) as well as a because it was evaluated clinically in eight of nine
concomitant injury of the opposite meniscus cases. Steenbrugge et al. (102) report a HSS score
(2,86,93). Reparable injuries are more frequent in of more than 75% of their population, with 85%
young individuals. of the patients having a normal knee function;
The lack of studies following the criteria of evi- out of the seven patients with an ACL rupture at
dence-based science such as prospective study follow-up examination, five had good to excellent
design, randomization, control groups, sufficientffi results. Similar conclusions were made by Kimura
patient number, and complete follow-up make the et al. (97), with all the patients presenting good to
evaluation of long-term results after meniscal excellent functional results according to the Lysh-
suture diffi
fficult. Ten studies dealing with the long- olm and Tegner scores.
term outcomes after open or arthroscopic menis- There is, however, a discrepancy between these
cal repair (>7 years) (60,94–102) and two studies good clinical results and the third-grade changes
on late midterm results after all-inside repair with of the meniscal tissue found in up to 40% of
the Meniscus ArrowTM (≥6 years) (103,104) have the patients on MRI scans. Steenbrugge et al.
been published until now. (102), describing hyperintense areas in 6 out of
Table 2 – Long-term results after meniscal repair.
Long-term follow-up (>7 years) after meniscal suture (open and arthroscopic)
Authors Year Patient number ACL rupture ACL repair Reruptures RX Function
Rate Arthritis Normal
Open ASC Stable Unstable Total + - + - Years ASC MRI Clinic Scores
(%) rate (%) (%)
DeHaven Lysholm,
1 1995 33 - 12 21 33 25 8 17 8 10.9 6 - 1 21 24 90
et al. Tegner
2 Eggli et al. 1995 - 52 52 - 52 5 47 - 52 7.5 12 ! - 23 - 90 IKDC
3 Muellner et al. 1999 23/(33) - 19 4 23 7 16 7 - 12.9 1 ! 1 9 26 91 OAK, Tegner
4 Johnson et al. 1999 - 38/(70) 32 6 38 ? ? - - 10.8 1 - 8 24 8 76 Clinic
Rockborn & Lysholm,
5 2000 30/(33) - 30 - 30 - 30 - - 13 7 - - 23 43 90
Messner Tegner
Rockborn & Lysholm,
6 2000 31/(34) - 31 - 31 - 31 - - 13 9 - - 29 23 80
Gillquist Tegner
7 Steenbrugge et al. 2002 - 13/(20) 6 7 13 7 6 1 6 13 - 1 - 8 - 85 HSS
8 Kimura et al. 2004 - 28/(54) 28 - 28 20 8 20 - 10.2 - 10 - 36 43 100
9 Majewski et al. 2006 - 88/(116) 88 - 88 - 88 - - 10 21 - - 24 20 78
IKDC, m.
10 Abdelkafy et al. 2007 - 41/(93) 41 - 41 16 41 16 - 11.7 5 - - 12 34 88
Late midterm follow-up (≥ 6 years) after arthroscopic all-inside repair with the Meniscus ArrowTM
11 Lee et al. 2005 - 28/(32) 21 7 28 32/32 - 32/32 - 6.6 7 - 1 29 - 71 IKDC
12 Siebold et al. 2007 - 95/(113) 95 - 95 75/113 38/113 75/113 - 6 27 - - 28 - 90
Ad 1: 30 patients, 33 menisci; Lysholm ≥ 80: normal knee function.
Ad 2: 5 patients with arthroscopically diagnosed, clinically stable ACL ruptures; radiographic and MRI exams were only performed in asymptomatic patients; 25 out of 40 patients without reruptures available for MRI examination, 24 of
these presenting 3rd or 4th grade lesions.
Ad 3: 10/32 patients (33 menisci) were not available for follow-up, thus a higher rerupture rate must be assumed; 19 patients underwent MRI scans, with 10 of them presenting 3rd grade lesions (the arthroscopic rerupture included).
Ad 4: Stability criterion was a pathologic clinical exam; no ACL lesions were described during primary surgery; only one rerupture was surgically treated.
Ad 5 + 6: Comparing both studies leads to the assumption that in part the same group was examined.
Ad 7: In this study, 7 ACL ruptures were diagnosed by MRI, one of these was treated surgically; the 7 knees are assumed to be unstable; rerupture rate was assessed by MRI.
Ad 8: None of the patients examined at follow-up had clinical meniscal signs, all knees were assessed with normal function; the rerupture rate of 36% was deduced from the ACL cases with 3rd grade lesions on MRI scans.
Ad 9: 24/88 patients were excluded from clinical and radiograpical follow-up because of reruptures or other complications.
Ad 11: In the best case scenario, in which it is assumed that the 4 patients who were lost to follow-up went on to successful meniscal healing, the success rate is 75%.
Ad 12: Not all the patients were assessed with the same scores; the 90% normal knee function result from the 41 patients assessed with the IKDC; the rerupture patients were not considered.
Meniscal sutures 133
134 The Traumatic Knee

13 patients, presumed that asymptomatic menisci In the recent literature, two papers report on
produce abnormal MRI signals, even though they late midterm results after meniscal repair with
have stable unions, and that MRI signals at the site all-inside devices. In 2005, Lee et al. presented a
of repair represent edematous scar tissue, not true case series investigating the outcome of menis-
non-unions. Eggli et al. (95) came to similar con- cal repair with the Meniscus ArrowTM (103). The Th
clusions in their study. They stated, after analyz- study was an extended follow-up of an original
ing their MRI results, that MRI deos not provide series of 32 patients with outcomes analysis. All
further information concerning the healing prop- patients underwent meniscal repair with exclusive
erties of the repaired menisci because of its lack use of the arrow, and all repairs were performed
of signal specification.
fi They recommended its use in the context of a concomitant ACL reconstruc-
only in the evaluation of shape and anatomic posi- tion. Intermediate follow-up at a mean of 2.3
tion of the sutured meniscus. years yielded a success rate of 90.6%. Th The mean
DeHaven et al. (60) made similar observations for follow-up then had been extended to 6.6 years.
joint function in case of rerupture of the menis- The extended follow-up analysis revealed a sub-
cus. The average Lysholm score for patients with stantial attrition in the success rate of this series
retears was 84, and the average Tegner score 6.1, of patients undergoing meniscal repair with the
thus indicating a normal knee function. Ninety- arrow. A 90.6% success rate at a mean follow-up
six percent of the patients returned to athletic of 2.3 years deteriorated to 71.4% at 6.6 years. At
levels of activity (postoperative Tegner scores the time of publication, the study provided the
between 5 and 10), with 91% of the patients with longest follow-up in the literature of any of the
successful repairs maintaining such levels during all-inside meniscal repair implants. Th The authors’
the 10 years of follow-up. Although the rerupture conclusion was that the Meniscus ArrowTM demon-
rate was 24%, Johnson et al. (96) reported 100% strated late midterm meniscal healing rates infe-
subjectively satisfied
fi patients. There seems to be rior to those found in the literature for inside-out
a mismatch between the functional results and suture repair techniques. Similar conclusions were
meniscus morphology; a non-union of the tear, made by Siebold et al. (104). In a level IV study,
respectively, an incomplete meniscal healing are they recently evaluated 113 consecutive patients
not necessarily associated with a bad functional with an arthroscopic all-inside Meniscus ArrowTM
outcome (Table 2). repair. The mean length of follow-up was 6 years;
The mid- and long-term functional outcome of
Th concomitant ACL reconstruction was performed in
meniscal suture repairs with the natural history of 66% of patients. TheTh Meniscus ArrowTM showed a
the uninjured knees of each of a cohort of patients high clinical failure rate of 28%. Furthermore, over
was assessed retrospectively by Majewski et al. (98) 80% of all failures occurred during the fi
first 3 post-
in 64 patients. The mean Tegner activity level was operative years, suggesting that the initial refix-
6 points (range, 3–10 points), the mean Lysholm ation potential of the Meniscus ArrowTM is low. On
score 94 points (range, 26–100 points). Seventy- the other hand, 90% of the patients were assessed
eight of the patients had a normal knee function, to the IKDC categories A or B, suggesting a normal
and a diff
fference between the injured and the unin- knee function.
jured joint could not be established. Especially the study by Siebold et al. (104) indi-
Two studies by Rockborn et al. (2000) deal with cates that the total failure rate of meniscal repair
the long-term results of meniscal repair, retrospec- with the Meniscus ArrowTM is comparable to that
tively compared to a control group after meniscec- of meniscal suture repair after 6 years. Th Thus, the
tomy. Startingly, at the 13-year follow-up, results conclusions that all-inside repair is inferior to
between groups were comparable for joint func- suture repair must be reformulated.
tion, subjective complaints, and manual findings.
The authors therefore recommend to weigh the
high functional scores after arthroscopic meniscec- Rerupture rate
tomy against the inconvenience of long rehabilita-
tion and long sick leave after meniscal repair. In about a quarter of the patients, a second inter-
Recently, a retrospective study with a long-term vention with partial meniscal resection or resuture
follow-up evaluation of the outside-in technique becomes necessary. The
Th rerupture rate in unstable
of arthroscopic meniscal repair was published by knee joints is higher than under stable conditions
Abdelkafy et al. (94). Out of the 41 patients avail- (60,99). The reviewed publications indicate a rerup-
able for follow-up evaluation, 36 repairs were clini- ture rate between 8–36% for meniscal sutures and
cally successful and 5 were considered as failures. 28 resp. 29% for all-inside devices (Table 2).
Eighty-eight percent of the patients had normal Some authors did not deduce the rerupture rate
knee function according to the IKDC- and SF-36 from the results of second-look arthroscopies,
scores. because the clinical situation did not justify an
Meniscal sutures 135

intervention, although imagery showed signs of of degeneration should not exceed the typical age-
meniscal lesions. The results presented in this related osteoarthritis rate. Long-term follow-up
review issue from arthroscopic, MRI, and clini- studies showed radiological degenerative changes
cal findings (Table 2). Thus the comparability and in 8–43% of the patients (Table 2). The radiologi-
interpretation of these studies is limited. cal changes were signifi ficantly higher in reruptures
Joint stability has been considered a crucial out- compared to patients without reruptures (57–15%
come factor; two out of four authors who per- (60) resp. 57–13% (100,101). In a study compar-
formed meniscal repair in unstable knees report a ing a group with partial meniscectomy and a group
higher number of reruptures in the ACL-deficientfi with meniscal repair, Rockborn and Gillquist (101)
group (60,99). Th
These results are concise with those found a trend to fewer signs of osteoarthritis in
found in the literature (105). DeHaven et al. (60), the repair group even if the groups were too small
however, conclude that their 67% survival rate sup- to show significant
fi diff
ports the practice of meniscal repair for patients The best results for postoperative manifestation of
who chose not to have ACL surgery on an unstable radiologic signs of arthritis were published by John-
knee. son et al. (96). In 38 knees available for follow-up,
The rerupture rates of open and arthroscopic only 3 showed minimal signs of degeneration on
meniscal repair do not seem to diff ffer in the long- x-rays; the control side presented 3% of radiologic
term follow-up. Also the latest publications on osteoarthritis signs. Thirty-two joints were stable,
late midterm results after meniscal repair with all- and 6 unstable; the correlation between degenera-
inside devices suggest rerupture rates similar to tive joint changes on x-rays and joint stability was
those of the conventional techniques (103,104). not evaluated.
In a long-term follow-up investigation, MRI Muellner et al. (99) report three out of five patients
showed a meniscal rupture in 1 out of 13 patients with degenerative changes on x-rays that had a
and signs of mucoid degeneration or scar tissue in concomitant ACL reconstruction at the time of
46% of the examined patients (102). TheseTh results meniscal repair. However, no mention of stability
are backed by data provided by Kimura et al. (97). assessment in these patients was made.
In a group of 28 patients, treated either by isolated In the above-mentioned study by Majewski et
meniscal repair or meniscal repair and concomit- al. (98), both the injured and the uninjured knee
tant ACL reconstruction, at a mean follow-up of 10 were radiographically examined in a retrospective
years, the evaluation of MRI scans showed grade 3 follow-up. Twenty-four out of 88 patients were
meniscal changes in 36% of the patients, all from excluded from the radiographic exam because
the ACL group. However, no meniscal signs or of reruptures or other complications. From the
symptoms were present, and no significant fi rela- remaining 64 patients, 46 presented osteoarthritic
tionship between findings of radiographs and MRI changes, compared with 27 of the uninjured knees
scans was apparent. Thus MRI must be viewed crit- (P = .004). However, 42 of the patients had no
ically as an appropriate diagnostic device for diag- diff
fference in the grade of osteoarthritis between
nosis of meniscus reruptures. the injured and the uninjured knee. According to
In a recent retrospective analysis of 88 arthroscop- the authors, the eff ffects of arthroscopic meniscal
ically performed meniscal sutures (mean follow-up repair on the risk of secondary osteoarthritis are
of 10 years) in isolated, longitudinal, vertical not clear.
tears of one of the menisci within a stable knee, With a similar purpose, Abdelkafy et al. (94) com-
the rerupture rate was indicated with 21% for the pared pre- and postoperative x-rays after menis-
lateral meniscus (8/38) and 26% for the medial cal repair. Preoperatively, 21 out of 24 knees were
meniscus (13/50). The total rerupture rate was considered as normal, whereas at follow-up, only
23.9% (21/88) (98). In the group examined by 12 out of 41 patients had no radiographic signs of
Abdelkafy et al. (94), there were 12.2% reruptures osteoarthritis. This was interpreted as a progres-
at a mean follow-up of 11.7 years. Out of initially sion of arthritis.
93 cases, only 41 patients were available for the As a summary of the previously mentioned stud-
follow-up evaluation; therefore, a higher number ies, a rerupture seems to occur in about 20–30% of
of failures might be suggested. meniscal repairs in the long term. Repaired menisci
seem to be able to fulfi fill their original function
both from the biomechanical and from the clini-
Radiologic signs of arthritis cal point of view. However, the exact influence
fl of
meniscal repair on the development of osteoarthri-
The biomechanical function of a sutured meniscus tis has not completely been elucidated yet. Recent
can indirectly be evaluated by the radiological signs investigations indicate that repair with meniscal
of arthritis. Supposing that a repaired meniscus has repair devices might be less favorable than initially
a similar function than the original tissue, the rate expected. However, further studies are needed to
136 The Traumatic Knee

firm the benefifit of meniscal repairs, either with comparison of two all-inside meniscal devices. J Knee
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20. Kocabey Y, Chang HC, Brand JC, et al. (2006) A biome-
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Chapitre 12

P. Verdonk,
P. Vansintjan, R. Verdonk
Meniscal allograft transplantation

History Meniscal allograft transplantation was first

introduced into clinical practice by Milachowsky

he surgical treatment of meniscal lesions is et al. in 1989. The senior authors started per-
the most common procedure in the ortho- forming this type of procedure in the same year.
paedic field today. Over 400,000 surgical We can now look back on a well-established
cases involving the meniscus are being performed series of over 250 patients treated with this type
annually in Europe and over 1 million in the United of surgery.
States. The majority of these lesions result in a
meniscectomy, while only a small percentage can
be successfully repaired. The discovery 50 years
ago that complete removal of a meniscus in the Biological basis
knee joint led to development of cartilage degen-
eration in the long term changed substantially The general biological basis of allograft transplan-
the therapeutic approach to this common work or tation is the concept of a timely colonization of the
sports injury (1). acellular scaff
ffold or allograft tissue by host cells,
Total meniscectomy is now almost completely which are probably derived from the synovium
abandoned in favor of partial meniscectomy and and joint capsule (Fig. 1) (9,10). The phenotype of
meniscus-repairing procedures. Both procedures these host-derived scaff ffold-colonizing cells ulti-
have the theoretical advantage of being less dam- mately determines the biochemical composition
aging to the articular cartilage. Long-term data and biomechanical behavior of these repopulated
to substantiate this hypothesis are, however, still scaff
ffolds or tissues.
missing. Nevertheless, total or subtotal meniscec- Another critical variab