Internal-external Rotational Laxity Research Articles

Influence of the posterior cruciate ligament on kinematics of the knee during experimentally simulated clinical tests and activities of daily living

Clinical outcomes following posterior cruciate ligament (PCL) reconstruction are often suboptimal. A better understanding of the biomechanical contributions of the PCL to knee stability under physiologic, clinically-relevant loading conditions could improve reconstruction techniques and outcomes. We employed a servohydraulic joint motion simulator to investigate the kinematics of intact and PCL-deficient knees during simulated clinical tests and activities of daily living(ADL), including gait, stair ascent and descent. PCL transection caused the tibia to be displaced posterior, relative to the intact joint, throughout flexion. PCL transection also increased the amount of posterior tibial displacement measured during posterior laxity testing by up to 9.6 ± 1.7 mm at 75° (p = 0.001). During internal-external rotational laxity testing, PCL transection increased the allowable internal and external rotation of the tibia, by up to 2.9 ± 0.5°at90° (p = 0.001) and 1.0 ± 0.2° at45°(p = 0.001), respectively. PCL transection did not have a significant effect on abduction–adduction kinematics or laxity, regardless of flexion angle. PCL transection resulted in a relative posterior displacement of the tibia during the stance phase of gait when the knee was extended (2.2 ± 2.2 mm, p = 0.045), and when the knee was flexed during stair ascent (2.4 ± 2.2 mm, p = 0.035) and descent (1.6 ± 1.4 mm, p = 0.037). Our results support previous studies of the role of the PCL on neutral joint kinematics and laxity, and provide new data quantifying the effect of PCL transection on AP kinematics during simulated ADL.

Investigation of the Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In-situ Force

Category: Basic Sciences/Biologics Introduction/Purpose: Ankle sprains are the most common sports injuries, and anterior talofibular ligament (ATFL) injury comprised 85% of all ankle sprains. Most patients recover with conservative treatment, but 20% of them progress to chronic ankle instability. Some studies have reported that anatomic reconstruction using a tendon graft is one of the best procedures to restore the ankle to its condition before symptom development. However, the effect of initial graft tension during ATFL reconstruction is still unclear. Therefore, the objective of this study was to investigate the effect of the initial graft tension during ATFL reconstruction. Methods: Eight fresh-frozen cadaveric ankle specimens were subjected to passive plantarflexion (PF)-dorsiflexion (DF) movement from 15° DF to 30° PF using the 6-degree-freedom robotic system. In addition, 60 N of anterior-posterior load, 1.7 Nm of inversion-eversion (IV-EV) torque, and 1.7 Nm of internal-external rotation (IR-ER) torque were applied to the ankle. During testing, 3-dimensional paths of the ankle were recorded simultaneously. Furthermore, in-situ forces of the ATFL and reconstructed graft were calculated using the principle of superposition. A repeated experiment was designed with the intact condition (intact), ATFL transection, and ATFL reconstruction with four different initial graft tensions (10 N, 30 N, 50 N, and 70 N). Results: AP laxity, IV-EV laxity and IR-ER laxity with ATFL transection was significantly greater than those with intact. In ATFL transection, the talus was significantly translated anteriorly with inversion and internal rotations under passive PF-DF motion compared with intact. Kinematic patterns and laxity in ATFL reconstruction with initial tension of 10 N and 30 N almost imitated intact, but in ATFL reconstruction with initial tension 70 N, the talus was significantly translated with external rotation compared with intact. As the initial graft tension during ATFL reconstruction increased, in-situ force of the reconstructed graft tended to increase during PF-DF motion. In-situ force of the reconstructed graft tension was significantly greater with initial tensions of 50 N, and 70 N than with intact during PF-DF motion (Figure 1). Conclusion: ATFL deficiency altered ankle kinematics and laxity. Although the optimal initial graft tension during ATFL reconstruction might restore ankle kinematics and laxity, excessive initial graft tension caused abnormal kinematics and laxity. Furthermore, the reconstructed graft tension increased as the initial tension increased. Initial tension during ATFL reconstruction has the important effect of imitating the normal ankle condition. We suggest that over-tensioning during ATFL reconstruction should be avoided in order to imitate the conditions of a normal ankle.

Is Soft Tissue Laxity Associated with Tissue Metal Concentrations after Total Knee Arthroplasty?

Increased joint laxity is associated with excessive polyethylene wear, but the correlation between laxity and metal wear has not been established. Fifteen necropsy-retrieved primary total knee replacements were mounted into a custom knee-testing machine that measured anterior-posterior, varus-valgus, and internal-external rotational laxity at 0°, 30°, 60°, and 90° of flexion. Inductively coupled plasma-mass spectrometry analysis was performed to measure the cobalt (Co), chromium (Cr), and titanium (Ti) concentrations in periprosthetic tissue samples. Spearman's rank correlations were performed to determine whether a significant correlation (p < 0.05) existed between soft tissue laxity and tissue metal concentrations. At 0° flexion, decreased posterior displacement was negatively correlated with elevated Co and Cr concentrations. At 30° flexion, decreased external rotation and varus deflection was negatively correlated with elevated Ti concentrations. At 60° flexion, decreased anterior displacement was negatively correlated with elevated Cr concentrations and decreased varus deflection was negatively correlated with increased Ti concentrations. At 90° flexion, decreased anterior displacement was negatively correlated with elevated Co and Cr concentrations. To our knowledge, this is the first study to investigate the correlation between tissue metal concentration and laxity. Decreased laxity was associated with elevated metal concentrations in periprosthetic tissue.

Assessment of the midflexion rotational laxity in posterior-stabilized total knee arthroplasty.

To evaluate changes in midflexion rotational laxity before and after posterior-stabilized (PS)-total knee arthroplasty (TKA). Twenty-nine knees that underwent PS-TKA were evaluated. Manual mild passive rotational stress was applied to the knees, and the internal-external rotational angle was measured automatically by a navigation system at 30°, 45°, 60°, and 90° of knee flexion. The post-operative internal rotational laxity was statistically significantly increased compared to the preoperative level at 30°, 45°, 60°, and 90° of flexion. The post-operative external rotational laxity was statistically significantly decreased compared to the preoperative level at 45° and 60° of flexion. The post-operative internal-external rotational laxity was statistically significantly increased compared to the preoperative level only at 30° of flexion. The preoperative and post-operative rotational laxity showed a significant correlation at 30°, 45°, 60°, and 90° of flexion. Internal-external rotational laxity increases at the initial flexion range due to resection of both the anterior or posterior cruciate ligaments and retention of the collateral ligaments in PS-TKA. Preoperative and post-operative rotational laxity indicated a significant correlation at the midflexion range. This study showed that a large preoperative rotational laxity increased the risk of a large post-operative laxity, especially at the initial flexion range in PS-TKA. III.

Clinical and instrumented measurements of hip laxity and their associations with knee laxity and general joint laxity.

Hip-joint laxity may be a relevant anterior cruciate ligament injury risk factor. With no devices currently available to measure hip laxity, it is important to determine if clinical measurements sufficiently capture passive displacement of the hip. To examine agreement between hip internal-external-rotation range of motion measured clinically (HIER(ROM)) versus internal-external-rotation laxity measured at a fixed load (HIER(LAX)) and to determine their relationships with knee laxity (anterior-posterior [KAP(LAX)], varus-valgus [KVV(LAX)], and internal-external rotation [KIER(LAX)]) and general joint laxity (GJL). Design : Cross-sectional study. Controlled research laboratory. Thirty-two healthy adults (16 women, 16 men; age = 25.56 ± 4.08 years, height = 170.94 ± 10.62 cm, weight = 68.86 ± 14.89 kg). Participants were measured for HIER(ROM), HIER(LAX) at 0° and 30° hip flexion (-10 Nm, 7 Nm), KAP(LAX) (-90 N to 133 N), KVV(LAX) (±10 Nm), KIER(LAX) (±5 Nm), and GJL. We calculated Pearson correlations and 95% limits of agreement between HIER(ROM) and HIER(LAX)_0° and HIER(LAX)_30°. Correlation analyses examined the strength of associations between hip laxity, knee laxity, and GJL. The HIER(ROM) and HIER(LAX) had similar measurement precision and were strongly correlated (r > 0.78). However, HIER(ROM) was systematically smaller in magnitude than HIER(LAX) at 0° (95% limits of agreement = 29.0° ± 22.3°) and 30° (21.4° ± 19.3°). The HIER(ROM) (r = 0.51-0.66), HIER(LAX)_0° (r = 0.52-0.69) and HIER(LAX)_30° (r = 0.53-0.76) were similarly correlated with knee laxity measures and GJL. The combinations of KVV(LAX) and either HIER(ROM), HIER(LAX)_0°, or HIER(LAX)_30° (R2 range, 0.42-0.44) were the strongest predictors of GJL. Although HIER(ROM) and HIER(LAX) differed in magnitude, they were measured with similar consistency and precision and were similarly correlated with knee laxity and GJL measures. Individuals with greater GJL also had greater hip laxity. These findings are relevant to clinicians and investigators conducting prospective risk factor studies, given the need for accessible, efficient, and low-cost alternatives for characterizing an individual's laxity profile.

A Clinical Device for Measuring Internal-External Rotational Laxity of the Knee

Background: The dial test can be improved by providing reproducible, accurate measurements to improve diagnosis and treatment comparisons. Purpose: Validation of a rotational measurement device (RMD) for measuring knee internal-external rotational laxity. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The RMD consisted of 3 components: a femoral clamp and a tibial splint using paired inclinometers to measure rotations, and a boot to apply tibial internal-external rotation torque. A separate boot inclinometer allowed for foot rotations to be measured independently. The measurements were simultaneously compared with electromagnetic “nest of birds” (NOB) sensors. Sequential paired knee measurements were taken at 4, 6, and 8 N·m of torque at 30° and 90° of flexion in 46 volunteers. Results: The correlation coefficient was 0.92 (95% CI, 0.89 to 0.94) and 0.63 (95% CI, 0.54 to 0.70) between the NOB and RMD and between the NOB and boot inclinometer, respectively. Bland-Altman analysis revealed that the RMD was on average within 2° (95% CI, 1° to −4°) of NOB readings, whereas the boot overestimated by 34° (95% CI, −9° to −58°). Maximum side-to-side differences measured by the NOB, RMD, and boot were 1°, 3°, and 21°, respectively. The mean +2× standard deviation data gave a range of side-to-side differences of less than 5° for the RMD. The intraobserver intraclass correlation was 0.9 (95% CI, 0.78 to 0.97) at both 30° and 90° of flexion, and the 95% CI of the differences between readings taken on 2 occasions, the interobserver repeatability, was 1° or less. Conclusion: The novel clinical RMD for measuring rotational laxity of the knee was portable, easy, and comfortable to use in the clinical setting. The RMD showed significant correlation and accuracy compared with sensors of known high accuracy. Side-to-side differences of less than 5° were found in 95% of normal knees, compared with differences of 13° or more for clinical diagnosis of pathological rotational laxity. Measuring knee rotation at the foot showed poor correlation and accuracy.

Identifying Multiplanar Knee Laxity Profiles and Associated Physical Characteristics

A single measure of knee laxity (ie, measurement of laxity in a single plane of motion) is probably inadequate to fully describe how knee joint laxity is associated with anterior cruciate ligament injury. To characterize interparticipant differences in the absolute and relative magnitudes of multiplanar knee laxity (ie, sagittal, frontal, and transverse planes) and examine physical characteristics that may contribute to these differences. Descriptive laboratory study. University research laboratory. 140 participants (90 women, 50 men). Using cluster analysis, we grouped participants into distinct multiplanar knee laxity profiles based on the absolute and relative magnitudes of their anterior knee laxity (AKL), genu recurvatum (GR), and varusvalgus (VV) and internal-external rotation (IER) knee laxity. Using multinomial logistic regression, we then examined associations between the different laxity profile clusters and physical characteristics of sex, age, activity level, general joint laxity, body mass index, thigh strength, and 8 measures of lower extremity anatomical alignment. Six clusters were identified: low (LOW), moderate (MOD) and high (HIGH) laxity overall and disproportionally higher VV/IER (MOD(VV/IER)), GR (HIGH(GR)), and AKL (HIGH(AKL)) laxity. Once all other physical characteristics were accounted for, the LOW cluster was more likely to be older, with longer femur length. Clusters with greater magnitudes of VV and IER laxity were more likely to be younger and to have lower body mass index, smaller Q-angle, and shorter femur length (MOD, HIGH, MOD(VV/IER)) and less thigh strength (HIGH). The HIGH(GR) cluster was more likely to be female and to have a smaller tibiofemoral angle and longer femur length. The HIGH(AKL) cluster was more likely to have greater hip anteversion and navicular drop. The absolute and relative magnitudes of a person's multiplanar knee laxity are not always uniform across planes of motion and can be influenced by age, body composition, thigh strength, and structural alignment. Except in HIGH(GR), sex was not a significant predictor of cluster membership once other physical characteristics were taken into account.

Biomechanical and Anatomical Assessment after Knee Hyperextension Injury

Background Knee hyperextension can be a serious and disabling injury in both the athletic and general patient population. Understanding the pathoanatomy and pathomechanics is critical for accurate surgical soft tissue reconstructions. Purpose To quantify the effects of knee hyperextension injury on knee laxity in a human cadaveric model and to qualitatively assess the anatomical injury pattern through surgical dissection. Study Design Descriptive laboratory study. Methods Six fresh-frozen cadaveric knees were rigidly mounted on a custom knee testing system that simulates clinical laxity tests. The knee laxity measurements consisted of anterior-posterior laxity, internal-external rotational laxity, and varus-valgus laxity using a custom testing setup and a Microscribe 3DLX system. The laxity data were collected at both 30° and 90° of knee flexion for the intact specimens and then after 15° and 30° hyperextension injury. After biomechanical assessment a detailed dissection was performed to document the injured structures in the knee. Repeated-measures analysis of variance with a Tukey post hoc test (P < .05) was used for statistical comparison. Results The results from this study suggest progressive damage to translational and rotational knee soft-tissue restraints with increasing knee hyperextension. Knee hyperextension to 30° caused the most significant increase in anterior-posterior and rotational laxity. Anatomical dissections showed a general injury pattern to the posterolateral corner, partial femoral anterior cruciate ligament avulsion in 4 of 6 specimens, and no gross posterior cruciate ligament injuries. Conclusion Injuries to the posterolateral corner of the knee can result from isolated knee hyperextension. Clinical Relevance The clinician should be aware of the potential for posterolateral corner injuries with isolated knee hyperextension. This will allow early surgical planning and primary surgical repair.

The TRAC PS mobile-bearing prosthesis: Design rationale and in vivo 3-dimensional laxity

We present a posterior stabilized mobile-bearing prosthesis, TRAC PS, which has congruent contact from full extension to full flexion, allows for freedom of internal-external rotation, and has an automatic posterior shift in tibiofemoral contact on the tibia to maximize the quadriceps lever arm in flexion. TRAC PS has 2 radii of curvature in the sagittal plane, 1 for the distal femoral condyles and 1 for the posterior femoral condyles, as does the normal knee. The distal and posterior femoral condyles articulate congruently in the inner tracks or the outer tracks of the polyethylene bearing, respectively. Anterior or posterior sliding of the femoral condyles on the bearing or of the bearing on the tibial tray cannot occur, providing inherent anterior and posterior stability. Three-dimensional knee laxity testing was performed on 17 patients from 12 months to 25 months after total knee arthroplasty with the TRAC PS and on 18 healthy control subjects of similar ages. Normal ligament balancing and normal internal-external rotational laxity were achieved with the TRAC PS prosthesis. Anterior and posterior laxity in the patients with TRAC PC was significantly reduced compared with that of the control subjects.

Validation of a three-dimensional model of the knee

Three-dimensional mathematical models of the tibio-femoral joint require input of the geometry of articulating surfaces and ligament insertions, and the mechanical properties of cartilage and ligaments. This paper describes a validation of a knee model through a direct specimen-related comparison between the knee model and the kinematics of four knee joint specimens from which the geometry data were used as input of the model. The knee model is quasi-static and is based on equilibrium of forces and moments. The stiffness properties of the ligaments and articular cartilage were estimated on the basis of data reported in the literature. The so-called reference strains in the ligament bundles for the joint in extension, were determined by using an optimization procedure, minimizing the difference between the kinematics of the model and the kinematics of experimentally obtained flexion motions with an internally or an externally rotated tibia (±3 Nm load). A reasonable to good agreement between the model and the experimental kinematics could be obtained for internal-external rotation laxity and the coupled translations and varus-valgus rotation. The disparity between model and experiment varied from knee to knee, average deviations ranging from close to zero to 8° internal rotation deviation and from 5 mm posterior to 3 mm anterior position deviation. The average anterior-posterior laxities at both 20° and 90° flexion were within the variations reported in the literature, although for each individual joint with some underestimation or overestimation. It was concluded that the optimization procedure compensated for the lack of menisci and capsular structures by higher prestrains, thereby overestimating the ligament forces. Despite the gross simplifications relative to the complex anatomy of the knee, the present knee model can realistically simulate the passive motion characteristics of the human knee joint.

Ligament-Bone Interaction in a Three-Dimensional Model of the Knee

In mathematical knee-joint models, the ligaments are usually represented by straight-line elements, connecting the insertions of the femur and tibia. Such a model may not be valid if a ligament is bent in its course over bony-surfaces, particularly not if the resulting redirection of the ligament force has a considerable effect on the laxity or motion characteristics of the knee-joint model. In the present study, a model for wrapping of a ligament around bone was incorporated in a three-dimensional mathematical model of the human knee. The bony edge was described by a curved line on which the contact point of the line element representing a ligament bundle was located. Frictionless contact between the ligament bundle and the bone was assumed. This model was applied to the medial collateral ligament (MCL) interacting with the bony edge of the tibia. It was found that, in comparison with the original model without bony interactions, the bony edge redirected the ligament force of the MCL in such a way that it counterbalanced valgus moments on the tibia more effectively. The effect of the bony interaction with the MCL on the internal-external rotation laxity, however, was negligible.

The contribution of the anterior talofibular ligament to ankle laxity.

The motion responses of thirty fresh-frozen cadaver tibiotalar joints were measured for applied anterior-posterior force, inversion-eversion moment, and internal-external rotary torque. The load-motion response curves obtained after sectioning the anterior talofibular ligament were compared with those for intact specimens in three positions of flexion of the ankle. Laxity of the intact ankle was shown to be dependent on flexion position; dorsiflexion was consistently the position of least laxity, reflecting the effects of talar geometry and its articulation with the tibiotalar syndesmosis. Section of the anterior talofibular ligament produced significant increases in laxity for all modes tested. Total anterior-posterior laxity increased by 4.3 millimeters in dorsiflexion, which was the position of maximum change. In contrast, the greatest increases in total inversion-eversion laxity (5.2 degrees) and total internal-external rotation laxity (10.8 degrees) were recorded in plantar flexion.