Rev. bras. ortop. vol.49 número5

w w w . r b o . o r g . b r

Original

Article

Anatomical

study

of

the

posterior

cruciate

ligament

with

the

knee

flexed

at

90

◦

夽

,

夽夽

Daniel

Kyubin

Cho,

Sthéphano

Pellizzaro

Rosa,

Guilherme

Bello

Prestes,

Luiz

Antônio

Munhoz

da

Cunha,

Márcio

Fernando

Aparecido

de

Moura,

Edmar

Stieven

Filho

UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil

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o

Articlehistory:

Received15July2013 Accepted20August2013 Availableonline27August2014

Keywords:

Posteriorcruciateligament Anatomy

Cadaver

a

b

s

t

r

a

c

t

Objective:Tostudytheanatomyoftheposteriorcruciateligament(PCL)anddefine anatom-icalparameterswiththekneeflexedat90◦_.

Methods:Eightkneesfromcadaversweredissectedinordertomakemeasurementsfromthe centeroftheanterolateralbandtotheroof(AL1),fromthecenteroftheanterolateralband totheanteriorcartilage(AL2),fromthecenteroftheposteromedialbandtotheroof(PM1), fromthecenteroftheposteromedialbandtotheanteriorcartilage(PM2),fromthecenter ofthetibialinsertiontothemedialregionofthetibia(TIM),fromthecenterofthetibial insertiontothelateralregionofthetibia(TIL),fromthecenterofthemedialinsertiontothe medialmeniscus(IMM)andthewidthoftheoriginofthePCL(WO).Toobtaintheresults fromeachanatomicalstructure,themeansandstandarddeviationsofthemeasurements werecalculated.

Results:ThemeasurementsinmillimetersthatwerefoundwereAL1,6.2;AL2,4.9;PM1,11.7; PM2,5.5;TIM,32.5;TIL,40.6;IMM,9.4;andWO,32.5.

Conclusions:ThePCLhasanextensiveorigin.Thecenteroftheanterolateralbandis6mm fromtheroofand5mmfromtheanteriorcartilageoftheknee.Thetibialinsertionisslightly medialand10mmdistaltotheposteriorcornuofthemedialmeniscus.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Estudo

anatômico

do

ligamento

cruzado

posterior

com

o

joelho

em

90

_de

flexão

Palavras-chave:

Ligamentocruzadoposterior

r

e

s

u

m

o

Objetivo:Estudara anatomiadoligamentocruzadoposterior(LCP)edefinir parâmetros anatômicoscomojoelhoem90◦_deflexão.

夽

Pleasecitethisarticleas:ChoDK,RosaSP,PrestesGB,daCunhaLAM,deMouraMFA,StievenFilhoE.Estudoanatômicodoligamento cruzadoposteriorcomojoelhoem90◦_{deflexão.RevBrasOrtop.2014;49(5):494–8.}

夽夽

WorkdevelopedintheBiologicalSciencesSector,UniversidadeFederaldoParaná(UFPR),Curitiba,PR,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected],[email protected](E.StievenFilho).

http://dx.doi.org/10.1016/j.rboe.2014.08.003

Anatomia Cadáver

Métodos: Oitojoelhosdecadáveresforamdissecadosparatirarasmedidasdocentroda bandaanterolateralaoteto(AL1),docentrodabandaanterolateralàcartilagemanterior (AL2),docentrodabandaposteromedialaoteto(PM1),docentrodabandaposteromedial àcartilagemanterior(PM2),docentrodainserc¸ãotibialàregiãomedialdatíbia(ITM),do centroda inserc¸ãotibialàregiãolateraldatíbia(ITL),docentroda inserc¸ãomedialao meniscomedial(IMM)edalarguradaorigemdoLCP(LO).Paraaobtenc¸ãodosresultados decadaestruturaanatômicaforamcalculadososvaloresdemédiaedesviopadrãodas medic¸ões.

Resultados: Asmedidas,emmilímetros,encontradasforamAL1,6,2;AL2,4,9;PM1,11,7; PM2,5,5;ITM,32,5;ITL,40,6;IMM,9,4;eLO,32,5.

Conclusões: OLCPtemumaorigemextensa.Ocentrodabandaanterolateralficaa6mm dotetoea5mmdacartilagemanteriordojoelho.Ainserc¸ãotibialficalevementemediale 10mmdistalaocornoposteriordomeniscomedial.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Theposteriorcruciateligament(PCL)isoneofthestatic sta-bilizersoftheknee.Itprovidesprimaryrestraintinrelationto posteriordisplacementofthetibiaandsecondaryrestraintin relationtovarus,valgusandexternalrotation.1

Controversy continues regarding the treatment for PCL injuries.2_{Thereisinsufficientdataintheliteraturetobeable}

to standardize the indication.3 _{Someauthors have}

recom-mendedreconstructionofthePCLinpatientswithmorethan 10mmofposteriordisplacementwhopresentcomplaintsof painandinstabilityandwhodonotimprovewith conserva-tivetreatment.2,4_{Thisrecommendationisbasedonthefact}

that75%oftheresultsfromPCLreconstructionaregood.5

Notechniquepresentingprecisionandreproducibilityfor guidingtunnelpositioninginPCLreconstructionhasyetbeen developed.Thismaybebecausemoststudieshavebeen con-ductedwiththekneeintheanatomicalposition(extension), whereasthesurgicalprocedureisperformedwiththeknee flexed.6–8_{Theaimofthisstudywasanalyzetheanatomyof}

thePCLanddefineobjectiveanatomicalparameterswiththe kneeflexedat90◦_.

Materials

and

methods

Eightknees from cadavers were dissectedwith the aimof studying the anatomy and making measurements on the structuresandanatomicalrelationshipsofthePCL.

Asaninclusioncriterion,weselectedkneesfrom cadav-erswithintactkneestructures,includingthejoint capsule, withoutanypreviousarthrotomy.Allthekneeshadbeen con-servedinformol.

Tomakemeasurements,40×12needleswereusedtomark

outspecificpointsandthenanAeroSpace®_{metalpachymeter}

(150mm)wasused.

Thefollowingmeasurementsweremade:

• centeroftheanterolateralbandtotheroof(Fig.1); • center ofthe anterolateralband totheanterior cartilage

(Fig.1);

• centeroftheposteromedialbandtotheroof(Fig.1); • centeroftheposteromedialbandtotheanteriorcartilage

(Fig.1);

• centerofthetibialinsertiontothemedialregionofthetibia

(Fig.2);

• centerofthetibialinsertiontothelateralregionofthetibia

(Fig.2);

• center of the medial insertion to the medial meniscus

(Fig.2);

• widthoftheoriginofthePCL(Fig.3).

Oneofthemeasurementswasthewidthoftheoriginof thePCL.Thiswasmeasuredwiththeaidofacoloredstring, whichwaslaidalongtheentirelengthoftheligament(Fig.3).

Results

Themeansandstandarddeviations(SD)resultingfrom the measurements on the PCLatthe femoral origin and tibial insertionarepresentedinTables1and2.

Discussion

Most studies havemeasured the cruciate ligaments in the anatomicalposition,i.e.withthekneeextended.These mea-surementshavebeenbasedonthesagittalview,withremoval ofthefemoralcondyle.8_{Inthepresentstudy,theanatomical}

measurementsweremadewiththekneeflexedat90◦_,with

the intentionofincreasingtheapplicability ofthe studyto arthroscopicprocedures.6_{Evenwithsimilarmeasurements,}

the resultsmay showdiscrepanciesifobtainedindifferent manners.7,8

ThePCLoriginatesfromalargeareaofthemedialfemoral condyle and isinserted ina depression betweenthe tibial plateauscalledthefossaofthePCL.1_{Itisslightlymedialto}

theimaginaryaxisofkneerotation.9_{Theresultsfrom}

anatom-icalstudiesonthetibialinsertionofthePCLcorroboratethis affirmation.Lorenzetal.10_{foundthecenterofthetibial}

Fig.1–Measurementsfromthefemoraloriginoftheposteriorcruciateligament.AL1:centeroftheanterolateralbandto theroof;AL2:centeroftheanterolateralbandtotheanteriorcartilage;PM1:centeroftheposteromedialbandtotheroof; PM2:centeroftheposteromedialbandtotheanteriorcartilage.

studydemonstratedanevenmoremedialposition,withthe centerofthePCLinthetibiaat40.6mmfromthelateraledge and32.5mmfromthemedialedge.

Girgisetal.11 _{evaluatedthelengthofthefemoralorigin}

ofthePCLand arrivedatavalueof32mm.Theymadethe

Fig.2–Measurementsfromthefemoraloriginofthe posteriorcruciateligament.TIL:centerofthetibial

insertiontothelateralregionofthetibia;TIM:centerofthe tibialinsertiontothemedialregionofthetibia;IMM:center ofthemedialinsertiontothemedialmeniscus.

measurement as a straight line between the two furthest extremitiesandneglecteditsovalformat.Inthepresentstudy, the measurement was made ina similar manner, but the half-circumferencewasevaluatedandavalueof28.6mmwas obtained.

Thegreatextentoftheoriginmeansthatthefibersofthe PCLbehavedifferentlyaccordingtothedegreeofknee flex-ion. Thus, therewill alwaysbe somefibers under tension, independentofthepositionoftheknee. Thisphenomenon wasanalyzedbackinthe1970s,but inadescriptionofthe PCLasasinglestructure.11_{Studiesconductedmorerecently}

haveseparatedthePCLintotwobands:theanterolateralband

Table1–Meansandstandarddeviations(SD)ofthePCL measurementsatthefemoralorigin.

Values WO AL1 AL2 PM1 PM2

Mean 28.6 6.2 4.9 11.7 5.5

SD 1.7 1.2 1.1 2 1.2

WO,widthatorigin;AL1,centeroftheanterolateralbandtothe roof;AL2,centeroftheanterolateralbandtotheanteriorcartilage; PM1,centeroftheposteromedialbandtotheroof;PM2,centerof theposteromedialbandtotheanteriorcartilage.

remainstenseduringflexionandtheposteromedial,during extension.12

Theovaloriginmeasuring30mmmakesreproductionin surgicalproceduresdifficult.Oneofthe proposalsfor com-ingclosertothe originalanatomyhasbeen toperformthe reconstructionasadoubleband.Nonetheless,although dou-blebandsdemonstrategreaterinvitrostability,clinicalstudies havenotdemonstratedanyadvantagesincomparisonwith single bands.8 _{Even some biomechanical studies have not}

foundanydifferencebetweenthetwotechniques,especially inclinicalanalyses.13

There were five studies in the literature, in which the methodologyenabledcomparisonswithsomeoftheresults fromthepresentstudy.Thedistancefromthecenterofthe anterolateralbandtotheroofwasfoundtorangefrom13to 4.8mm.Inthepresentstudy,thisdistancewas6.2.The dis-tancefromtheposteromedialbandtotheroofrangedfrom20 to11.4mm.Inthepresentstudy,itwas11.7.8,14–16_Differences

ofthistypebetweenstudiesare common,becausetheyare absolutemeasurementsandareinfluencedbytheevaluator, thesampleandthematerialusedforcollection.

Regardingthemeasurementsfromthecenterofthebands totheanteriorcartilage,therewasadiscrepancyinrelationto thedatafoundintheliterature.Thedistancefromthe antero-lateralbandtotheanteriorcartilagerangedfrom13to7mm. Inthepresentstudy,thisdistancewas4.9.Forthe posterome-dialband,therangewasfrom10.6to8mm.Thevaluefound was5.5.8,14–16_{Onepossibilityforthisdifference,inadditionto}

thoseputforwardintheaboveparagraph,wasundervaluation ofHamphey’sligament.

Thearthroscopicreferencepointsfordeterminingthe posi-tionofthePCLareasourceofconfusionintheliterature.One ofthemethodsusedhasbeenaclock-facemethod.However, studieshaveshownthatthereisimprecisioninreproducing thistechnique.Insomecases,differencesofmorethanone hourwerefoundintheevaluationsbetweenobservers.17,18

Table2–Meansandstandarddeviations(SD)ofthePCL measurementsatthetibialinsertion.

Values TIM TIL IMM

Mean 32.5 40.6 9.4

SD 3.5 4.4 2.3

TIM,centerofthetibialinsertiontothemedialregionofthetibia; TIL,centerofthetibialinsertiontothelateralregionofthetibia; IMM,centerofthemedialinsertiontothemedialmeniscus.

Anothermethodusedconsistsofatabulatedguide.Thisis usefulforguidingthetunnelsonlateralimages.Thismethod standardizestheindividualizationofthebandsandtheir posi-tionsinrelationtothesizeoftheknee.Thismethodshould perhapsbethestandardfornavigatedsurgery,sinceitis math-ematicallymoreprecise.Ontheotherhand,forapplicationto conventionalarthroscopicsurgery,itisverylimited.18

Evenwithalltheseparameters,somedecisionsregarding thepositioningofthetunnelduringthesurgery,inrelationto boththejointfaceandthetunneldirection,aredependenton thesurgeon’ssubjectivechoicesandtheparticularfeaturesof thecaseoperated.

Conclusions

ThePCLhasanextensiveorigin.Thecenterofthe anterolat-eralbandis6mmfromtheroofand5mmfromtheanterior cartilageoftheknee.Thetibialinsertionisslightlymedialand 10mmdistaltotheposteriorcornuofthemedialmeniscus.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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