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

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