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Anatomy and Biomechanics of the Cruciate Ligaments and Their Surgical Implications

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The Multiple Ligament Injured Knee

Abstract

Multiple ligament knee injuries, although rare, are severe injuries because they result in the loss of the passive and active knee stabilizers as well as often being associated with the compromise of neurovascular structures. Treatment of these injuries is controversial, and results after surgery can sometimes be poor. After sustaining injuries to multiple ligaments, the knee is at a biomechanical disadvantage which poses a reconstructive and rehabilitative challenge to even the most experienced orthopedic surgeon. Surgeons performing reconstructions in patients with these injuries must have a complete understanding of the normal anatomy and biomechanics of the knee to optimize the timing of surgery, surgical approach, tunnel preparation, and the anatomic placement of grafts. This chapter outlines the anatomy and biomechanics of the cruciate ligaments and their surgical implications. The structure and form of the anterior and posterior cruciate ligaments, patterns of injury, structural properties of the cruciate ligaments and graft substitutes, functional biomechanics and interplay between the cruciate ligaments, and the surgical implications related to anatomic reconstruction of the anterior and posterior cruciate ligaments are all reviewed in detail.

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References

  1. Feagin JA. Isolated anterior cruciate injury. In: Feagin JA, editor. The cruciate ligaments. New York: Churchill Livingstone; 1988. p. 15–23.

    Google Scholar 

  2. Fu FH, Harner CD, Johnson DL, Miller MD, Woo SLY. Biomechanics of knee ligaments: basic concepts and clinical application. J Bone Joint Surg Am. 1993;75:1716–27.

    Google Scholar 

  3. Harner CD, Baek GH, Vogrin TM. Quantitative analysis of human cruciate ligament insertions. Arthroscopy. 1999;15:741–9.

    Article  PubMed  CAS  Google Scholar 

  4. Takahashi M, Doi M, Abe M, Suzuki D, Nagano A. Anatomical study of the femoral and tibial insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Am J Sports Med. 2006;34:787–92.

    Article  PubMed  Google Scholar 

  5. Smith BA, Livesay GA, Woo SL. Biology and biomechanics of the anterior cruciate ligament. Clin Sports Med. 1993;12:637–70.

    PubMed  CAS  Google Scholar 

  6. Forsythe B, Kopf S, Wong AK, et al. The location of femoral and tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional computed tomography models. J Bone Joint Surg Am. 2010;92:1418–26.

    Article  PubMed  Google Scholar 

  7. Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am. 2006;88:2–10.

    Article  PubMed  Google Scholar 

  8. Arnoczky SP. Anatomy of the anterior cruciate ligament. Clin Orthop. 1983;172:19–25.

    PubMed  Google Scholar 

  9. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. 1982;10:329–35.

    Article  PubMed  CAS  Google Scholar 

  10. Biedert RM, Stauffer E, Friederich NF. Occurrence of free nerve endings in the soft tissue of the knee joint. A histologic investigation. Am J Sports Med. 1992;20:430–3.

    Article  PubMed  CAS  Google Scholar 

  11. Shutte MJ, Dabezies EJ, Zimney ML, et al. Neural anatomy of the human anterior cruciate ligament. J Bone Joint Surg Am. 1987;69:243–7.

    Google Scholar 

  12. Harner CD, Xerogeanes JW, Livesay GA, et al. The human posterior cruciate ligament complex: an interdisciplinary study. Am J Sports Med. 1995;23:736–45.

    Article  PubMed  CAS  Google Scholar 

  13. Johnson CJ, Bach BR. Current concepts review. Posterior cruciate ligament. Am J Knee Surg. 1990;3:143–53.

    Google Scholar 

  14. Girgis FG, Marshall JL, Al Monajem ARS. The cruciate ligaments of the knee joint. Anatomic, functional, and experimental analysis. Clin Orthop. 1975;106:216–31.

    Article  PubMed  Google Scholar 

  15. Lopes OV, Ferretti M, Shen W, Ekdahl M, Smolinski P, Fu FH. Topography of the femoral attachment of the posterior cruciate ligament. J Bone Joint Surg Am. 2008;90:249–55.

    Article  PubMed  Google Scholar 

  16. Tajima G, Nozaki M, Iriuchishima T, et al. Morphology of the tibial insertion of the posterior cruciate ligament. J Bone Joint Surg Am. 2009;91:859–66.

    Article  PubMed  Google Scholar 

  17. Vladimirov B. Arterial sources of blood supply in the knee joint in man. Acta Med. 1968;47:1–10.

    CAS  Google Scholar 

  18. Zantop T, Brucker PU, Vidal A, Zelle BA, Fu FH. Intraarticular rupture pattern of the ACL. Clin Orthop Relat Res. 2007;454:48–53.

    Article  PubMed  Google Scholar 

  19. Miller MD, Cooper DE, Warner JJP. Review of sports medicine and arthroscopy. Philadelphia: WB Saunders; 1995. p. 3–71.

    Google Scholar 

  20. Prietto MP, Bain JR, Stonebrook SN, Settlage RA. Tensile strength of the human posterior cruciate ligament (PCL). Trans Orthop Res Soc. 1988;13:195.

    Google Scholar 

  21. Cooper DE, Deng XH, Burstein AL, Warren RF. The strength of the central third patellar tendon graft, a biomechanical study. Am J Sports Med. 1993;21:818–23.

    Article  PubMed  CAS  Google Scholar 

  22. Woo SLY, Debski RE, Withrow JD, Janaushek MA. Biomechanics of knee ligaments. Am J Sports Med. 1999;27:533–43.

    PubMed  CAS  Google Scholar 

  23. Miller MD. Sports medicine. In: Miller MD, editor. Review of orthopaedics. 3rd ed. Philadelphia: WB Saunders; 2000. p. 195–240.

    Google Scholar 

  24. Andriacchi TP. Knee joint, anatomy and biomechanics. In: Pellicci PM, Tria AJ, Garvin KL, editors. Orthopaedic knowledge update. Hip and Knee reconstruction 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2000. p. 239–49.

    Google Scholar 

  25. Lafortune MA, Cavanaugh PR, Sommer III HJ, Kalenak A. Three-dimensional kinematics of the human knee during walking. J Biomech. 1992;25:347–57.

    Article  PubMed  CAS  Google Scholar 

  26. Buoncristiani AM, Tjoumakaris FP, Starman JS, Ferretti M, Fu FH. Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2006;22:1000–6.

    Article  PubMed  Google Scholar 

  27. Sakane M, Fox RJ, Woo SL-Y, Livesay GA, Li G, Fu FH. In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res. 1997;15:285–93.

    Article  PubMed  CAS  Google Scholar 

  28. Butler DL, Noyes FR, Grood ES. Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study. J Bone Joint Surg Am. 1980;62:259–70.

    PubMed  CAS  Google Scholar 

  29. Butler DL, Guan Y, Kay MD, et al. Location-dependent variations in the material properties of anterior cruciate ligament subunits. Trans Orthop Res Soc. 1991;16:234.

    Google Scholar 

  30. Woo SLY, Adams DJ. The tensile properties of the human anterior cruciate ligament and ACL graft tissues. In: Daniel DM, Akeson WH, O’Conner JJ, editors. Knee ligaments, structure, function, injury, and repair. New York: Raven Press; 1990. p. 279–89.

    Google Scholar 

  31. Gollehon DL, Torzilli PA, Warren RF. The role of posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am. 1987;69:233–42.

    PubMed  CAS  Google Scholar 

  32. Grood ES, Stowers SF, Noyes FR. Limits of movement in the human knee. Effect of sectioning the posterior cruciate ligament and posterolateral structures. J Bone Joint Surg Am. 1988;70:88–97.

    PubMed  CAS  Google Scholar 

  33. Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2003;11:271–81.

    Article  PubMed  CAS  Google Scholar 

  34. Covey DC, Sapega AA. Anatomy and function of the posterior cruciate ligament. Clin Sports Med. 1994;13:509–18.

    PubMed  CAS  Google Scholar 

  35. Schulz MS, Steenlage ES, Russe K, Strobel MJ. Distribution of posterior tibial displacement in knees with posterior cruciate ligament tears. J Bone Joint Surg Am. 2007;89:332–8.

    Article  PubMed  Google Scholar 

  36. Covey DC, Sapega AA. Current concepts review. Injuries of the posterior cruciate ligament. J Bone Joint Surg Am. 1993;75:1376–86.

    PubMed  CAS  Google Scholar 

  37. Fox RJ, Harner CD, Sakane M, Carlin GJ, Woo SLY. Determination of the in situ forces in the human posterior cruciate ligament using robotic technology, a cadaveric study. Am J Sports Med. 1998;26:395–401.

    Article  PubMed  CAS  Google Scholar 

  38. Harner CD, Hoher J, Vogrin TM, Carlin GJ, Woo SLY. The effects of a popliteus muscle load on in situ forces of the posterior cruciate ligament and on knee kinematics. Am J Sports Med. 1998;26:669–73.

    PubMed  CAS  Google Scholar 

  39. Burstein AH, Wright TM. Biomechanics. In: Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P, editors. Surgery of the knee. 2nd ed. New York: Churchill Livingstone; 1993. p. 43–62.

    Google Scholar 

  40. Muller WD. Kinematics. In: Muller W, editor. The knee, form, function, and ligament reconstruction. New York: Springer; 1983. p. 8–28.

    Google Scholar 

  41. Morrison JB. The mechanics of the knee joint in relation to normal walking. J Biomech. 1970;3:51.

    Article  PubMed  CAS  Google Scholar 

  42. Elftman H. The forces exerted by the ground in walking. Arb Physiol. 1939;10:485.

    Google Scholar 

  43. Graf BK, Henry J, Rothenberg M, Vanderby R. Anterior cruciate ligament reconstruction with patellar tendon. An ex vivo study of wear-related damage and failure at the femoral tunnel. Am J Sports Med. 1994;22:131–5.

    Article  PubMed  CAS  Google Scholar 

  44. Katsuragi R, Yasuda K, Tsujino J, Keira M, Kaneda K. The effect of nonphysiologically high initial tension on the mechanical properties of in situ frozen anterior cruciate ligament in a canine model. Am J Sports Med. 2000;28:47–56.

    PubMed  CAS  Google Scholar 

  45. Yoshiya S, Andrish JT, Manley MT, Bauer TW. Graft tension in anterior cruciate ligament reconstruction. An in vivo study in dogs. Am J Sports Med. 1987;15:464–70.

    Article  PubMed  CAS  Google Scholar 

  46. Amis AA. Anterior cruciate ligament replacement. Knee stability and the effects of implants. J Bone Joint Surg Br. 1989;71:819–24.

    PubMed  CAS  Google Scholar 

  47. Bylski-Austrow DI, Grood ES, Hefzy MS, Holden JP, Butler DL. Anterior cruciate ligament replacements: a mechanical study of femoral attachment location, flexion angle at tensioning, and initial tension. J Orthop Res. 1990;8:522–31.

    Article  PubMed  CAS  Google Scholar 

  48. Gertel TH, Lew WD, Lewis JL, Stewart NJ, Hunter RE. Effect of anterior cruciate ligament graft tensioning direction, magnitude, and flexion angle on knee biomechanics. Am J Sports Med. 1993;21:572–81.

    Article  PubMed  CAS  Google Scholar 

  49. Melby 3rd A, Noble JS, Askew MJ, Boom AA, Hurst FW. The effects of graft tensioning on the laxity and kinematics of the anterior cruciate ligament reconstructed knee. Arthroscopy. 1991;7:257–66.

    Article  PubMed  Google Scholar 

  50. Cyril FB, Jackson DW. Current concepts review—the science of reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am. 1997;79:1556–76.

    Google Scholar 

  51. Simmons R, Howell SM, Hull ML. Effect of the angle of the femoral and tibial tunnels in the coronal plane and incremental excision of the posterior cruciate ligament on tension of an anterior cruciate ligament graft: an in vitro study. J Bone Joint Surg Am. 2003;85:1018–29.

    PubMed  Google Scholar 

  52. Shearn JT, Grood ES, Noyes FR, Levy MS. Two-bundle posterior cruciate ligament reconstruction: how bundle tension depends on femoral placement. J Bone Joint Surg Am. 2004;86:1262–70.

    PubMed  Google Scholar 

  53. Meyers M, Harvey JJ. Traumatic dislocations of the knee joint: a study of eighteen cases. J Bone Joint Surg Am. 1971;53:16–29.

    PubMed  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Banner Good Samaritan Orthopaedic Residency, 901 E. Willetta Street, 2nd floor, Phoenix, AZ, 85006, USA

    Christopher Kweon M.D.

  2. Sports Medicine Division, Orthopedic Surgery Department, The Orthopedic Clinic Association, Banner Good Samaritan Medical Center, 2222 E. Highland Avenue, #300, Phoenix, AZ, 85016, USA

    Evan S. Lederman M.D.

  3. Arizona State University, Sports Medicine, Banner Good Samaritan, Mayo Clinic Arizona, The Orthopedic Clinic Association, 2222 E. Highland Avenue, #300, Phoenix, AZ, 85016, USA

    Anikar Chhabra M.D., M.S.

Authors
  1. Christopher Kweon M.D.
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  2. Evan S. Lederman M.D.
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  3. Anikar Chhabra M.D., M.S.
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Correspondence to Christopher Kweon M.D. .

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Editors and Affiliations

  1. GHS Orthopaedics, Woodbine Lane 115, Danville, 17822-5212, Pennsylvania, USA

    Gregory C. Fanelli

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Kweon, C., Lederman, E.S., Chhabra, A. (2013). Anatomy and Biomechanics of the Cruciate Ligaments and Their Surgical Implications. In: Fanelli, G. (eds) The Multiple Ligament Injured Knee. Springer, New York, NY. https://doi.org/10.1007/978-0-387-49289-6_2

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  • DOI: https://doi.org/10.1007/978-0-387-49289-6_2

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  • Online ISBN: 978-0-387-49289-6

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