Abstract
The paper describes the concepts of primary and secondary restraints to knee joint stability and explains systematically how the tibia is stabilised against translational forces and rotational torques in different directions and axes, and how those vary across the arc of flexion–extension. It also shows how the menisci act to stabilise the knee, in addition to load carrying across the joint. It compares the properties of the natural stabilising structures with the strength and stiffness of autogenous tissue grafts and relates those strengths to the strength of graft fixation devices. A good understanding of the biomechanical behaviour of these various structures in the knee will help the surgeon in the assessment and treatment of single and multi-ligament injuries.
Similar content being viewed by others
References
Aga C, Rasmussen MT, Smith SD, Jansson KS, LaPrade RF, Engebretsen L, Wijdicks CA (2013) Biomechanical comparison of interference screws and combination screw and sheath devices for soft tissue anterior cruciate ligament reconstruction on the tibial side. Am J Sports Med 41(4):841–848
Andrews JR, Carson WGJ (1987) The role of extra-articular anterior cruciate ligament stabilization. In: Jackson DW, Drez DJ (eds) The anterior cruciate deficient knee. New concepts in ligament repair. CV Mosby, St. Louis, pp 168–192
Arno S, Hadley S, Campbell KA, Bell CP, Hall M, Beltran LS, Recht MP, Sherman OH, Walker PS (2013) The effect of arthroscopic partial medial meniscectomy on tibiofemoral stability. Am J Sports Med 41(1):73–79
Barcellona MG, Morrissey MC, Milligan P, Amis AA (2014) The effect of thigh muscle activity on anterior knee laxity in the uninjured and anterior cruciate ligament-injured knee. Knee Surg Sports Traumatol Arthrosc 22(11):2821–2829
Bull AM, Earnshaw PH, Smith A, Katchburian MV, Hassan AN, Amis AA (2002) Intraoperative measurement of knee kinematics in reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 84(7):1075–1081
Carson W Jr (1985) Extra-articular reconstruction of the anterior cruciate ligament: lateral procedures. Orthop Clin N Am 16(2):191–211
Claes S, Hermie L, Verdonk R, Bellemans J, Verdonk P (2012) Is osteoarthritis an inevitable consequence of anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol Arthrosc 21(9):1967–1976
Claes S, Luyckx T, Vereecke E, Bellemans J (2014) The Segond fracture: a bony injury of the anterolateral ligament of the knee. Arthroscopy 30(11):1475–1482
Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223(4):321–328
Cooper DE, Deng XH, Burstein AL, Warren RF (1993) The strength of the central third patellar tendon graft: a biomechanical study. Am J Sports Med 21(6):818–824
Cruells Vieira EL, Vieira EÁ, Teixeira da Silva R, dos Santos Berlfein PA, Abdalla RJ, Cohen M (2007) An anatomic study of the iliotibial tract. Arthroscopy 23(3):269–274
Desai N, Björnsson H, Musahl V, Bhandari M, Petzold M, Fu F, Samuelsson K (2014) Anatomic single- versus double-bundle ACL reconstruction: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 22(5):1009–1023
Dodds AL, Halewood C, Gupte CM, Williams A, Amis AA (2014) The anterolateral ligament: anatomy, length changes and association with the Segond fracture. Bone Joint J 96-B(3):325–331
Grood ES, Suntay WJ (1983) A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. J Biomech Eng 105(2):136
Gupte CM, Bull AM, Thomas RD, Amis AA (2003) The meniscofemoral ligaments: secondary restraints to the posterior drawer. Analysis of anteroposterior and rotary laxity in the intact and posterior-cruciate-deficient knee. J Bone Joint Surg Br 85(5):765–773
Hallen L, Lindahl O (1966) The “screw-home” movement in the knee-joint. Acta Orthop 37(1):97–106
Hamner DL, Brown C, Steiner ME, Hecker AT, Hayes WC (1999) Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 81(4):549–557
Hoshino Y, Araujo P, Ahldén M, Samuelsson K, Muller B, Hofbauer M, Wolf MR, Irrgang JJ, Fu FH, Musahl V (2013) Quantitative evaluation of the pivot shift by image analysis using the iPad. Knee Surg Sports Traumatol Arthrosc 21(4):975–980
Hughston JC, Eilers AF (1973) The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. J Bone Joint Surg Am 55(5):923–940
Irvine JN, Thorhauer E, Abebe ES, Tashman S, Harner CD (2014) ACL reconstruction: Is there a difference in graft motion for bone-patellar tendon-bone vs hamstring autograft at 6 weeks post-operatively? Orthop J Sports Med 2(2 suppl):2325967114S2325900044
Kawaguchi Y, Kondo E, Takeda R, Akita K, Yasuda K, Amis AA (2015) The role of fibers in the femoral attachment of the anterior cruciate ligament in resisting tibial displacement. Arthroscopy 31(3):435–444
Kennedy NI, LaPrade RF, Goldsmith MT, Faucett SC, Rasmussen MT, Coatney GA, Engebretsen L, Wijdicks CA (2014) Posterior cruciate ligament graft fixation angles, part 1: biomechanical evaluation for anatomic single-bundle reconstruction. Am J Sports Med 42(10):2338–2345
Kondo E, Merican AM, Yasuda K, Amis AA (2011) Biomechanical comparison of anatomic double-bundle, anatomic single-bundle, and nonanatomic single-bundle anterior cruciate ligament reconstructions. Am J Sports Med 39(2):279–288
Kousa P, Järvinen TLN, Vihavainen M, Kannus P, Järvinen M (2003) The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction: part I: femoral site. Am J Sports Med 31(2):174–181
LaPrade RF, Griffith CJ, Coobs BR, Geeslin AG, Johansen S, Engebretsen L (2014) Improving outcomes for posterolateral knee injuries. J Orthop Res 32(4):485–491
LaPrade RF, Ly TV, Wentorf FA, Engebretsen L (2003) The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med 31(6):854–860
LaPrade RF, Morgan PM, Wentorf FA, Johansen S, Engebretsen L (2007) The anatomy of the posterior aspect of the knee. J Bone Joint Surg Am 89(4):758–764
LaPrade RF, Wozniczka JK, Stellmaker MP, Wijdicks CA (2010) Analysis of the static function of the popliteus tendon and evaluation of an anatomic reconstruction the “fifth ligament” of the knee. Am J Sports Med 38(3):543–549
Li Y-L, Ning G-Z, Wu Q, Wu Q-L, Li Y, Hao Y, Feng S-Q (2014) Single-bundle or double-bundle for anterior cruciate ligament reconstruction: a meta-analysis. Knee 21(1):28–37
Linko E, Harilainen A, Malmivaara A, Seitsalo S (2005) Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults. Cochrane Database Syst Rev (2). doi:10.1002/14651858.CD001356.pub3
Lopomo N, Zaffagnini S, Amis AA (2013) Quantifying the pivot shift test: a systematic review. Knee Surg Sports Traumatol Arthrosc 21(4):767–783
MacIntosh D, Darby T (1976) Lateral substitution reconstruction. J Bone Joint Surg Am 58:142
Maletis G, Inacio M, Desmond J, Funahashi T (2013) Reconstruction of the anterior cruciate ligament Association of graft choice with increased risk of early revision. Bone Joint J 95(5):623–628
Matsumoto H (1990) Mechanism of the pivot shift. J Bone Joint Surg Br 72(5):816–821
Merican AM, Amis AA (2009) Iliotibial band tension affects patellofemoral and tibiofemoral kinematics. J Biomech 42(10):1539–1546
Merican AM, Iranpour F, Amis AA (2009) Iliotibial band tension reduces patellar lateral stability. J Orthop Res 27(3):335–339
Miyatake S, Kondo E, Tsai T-Y, Hirschmann M, Halewood C, Jakobsen BW, Yasuda K, Amis AA (2011) Biomechanical comparisons between 4-strand and modified larson 2-strand procedures for reconstruction of the posterolateral corner of the knee. Am J Sports Med 39(7):1462–1469
Mohtadi NGH, Chan DS, Dainty KN, Whelan DB (2011) Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev (9):CD005960
Morgan PM, LaPrade RF, Wentorf FA, Cook JW, Bianco A (2010) The role of the oblique popliteal ligament and other structures in preventing knee hyperextension. Am J Sports Med 38(3):550–557
Mundasad S (2013) New ligament discovered in knee, Belgian surgeons say. http://www.bbc.co.uk/news/health-24826323
Musahl V, Seil R, Zaffagnini S, Tashman S, Karlsson J (2012) The role of static and dynamic rotatory laxity testing in evaluating ACL injury. Knee Surg Sports Traumatol Arthrosc 20(4):603–612
Musahl V, Voos J, O’Loughlin PF, Stueber V, Kendoff D, Pearle AD (2010) Mechanized pivot shift test achieves greater accuracy than manual pivot shift test. Knee Surg Sports Traumatol Arthrosc 18(9):1208–1213
Nesbitt RJ, Herfat ST, Boguszewski DV, Engel AJ, Galloway MT, Shearn JT (2014) Primary and secondary restraints of human and ovine knees for simulated in vivo gait kinematics. J Biomech 47(9):2022–2027
Peccin MS, Almeida GJM, Amaro JT, Cohen M, Soares BGO, Atallah ÁN (2012) Interventions for treating posterior cruciate ligament injuries of the knee in adults. Cochrane Database Syst Rev (2):CD002939
Petre BM, Smith SD, Jansson KS, de Meijer P-P, Hackett TR, LaPrade RF, Wijdicks CA (2013) Femoral cortical suspension devices for soft tissue anterior cruciate ligament reconstruction: a comparative biomechanical study. Am J Sports Med 41(2):416–422
Race A, Amis AA (1994) The mechanical properties of the two bundles of the human posterior cruciate ligament. J Biomech 27(1):13–24
Race A, Amis AA (1996) Loading of the two bundles of the posterior cruciate ligament: an analysis of bundle function in A–P drawer. J Biomech 29(7):873–879
Robinson JR, Bull AM, Amis AA (2005) Structural properties of the medial collateral ligament complex of the human knee. J Biomech 38(5):1067–1074
Salzler MJ, Harner CD (2014) Tunnel placement for the ACL during reconstructive surgery of the knee. J Bone Joint Surg Rev 2(4):e3
Sanchez AR, Sugalski MT, LaPrade RF (2006) Anatomy and biomechanics of the lateral side of the knee. Sports Med Arthroscopy Rev 14(1):2–11
Schulz M, Russe K, Weiler A, Eichhorn H, Strobel M (2003) Epidemiology of posterior cruciate ligament injuries. Arch Orthop Trauma Surg 123(4):186–191
Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX, Seil R (2014) Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic exploration of the concealed portion of the knee. Am J Sports Med 42:921–926
Sugita T, Amis AA (2001) Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments. Am J Sports Med 29(4):466–472
Tiamklang T, Sumanont S, Foocharoen T, Laopaiboon M (2012) Double-bundle versus single-bundle reconstruction for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev (11). doi:10.1002/14651858.CD008413.pub2
Vavken P, Murray MM (2013) ACL injury epidemiology. In: Murray MM, Vavken P, Fleming B (eds) The ACL handbook. Springer, New York, pp 3–17
Veltri DM, Deng X-H, Torzilli PA, Maynard MJ, Warren RF (1996) The role of the popliteofibular ligament in stability of the human knee: a biomechanical study. Am J Sports Med 24(1):19–27
Vincent J-P, Magnussen R, Gezmez F, Uguen A, Jacobi M, Weppe F, Ma Al-Saati, Lustig S, Demey G, Servien E, Neyret P (2012) The anterolateral ligament of the human knee: an anatomic and histologic study. Knee Surg Sports Traumatol Arthrosc 20(1):147–152
Wijdicks CA, Kennedy NI, Goldsmith MT, Devitt BM, Michalski MP, Årøen A, Engebretsen L, LaPrade RF (2013) Kinematic analysis of the posterior cruciate ligament, part 2: a comparison of anatomic single- versus double-bundle reconstruction. Am J Sports Med 41(12):2839–2848
Woo SL-Y, Hollis JM, Adams DJ, Lyon RM, Takai S (1991) Tensile properties of the human femur-anterior cruciate ligament-tibia complex: the effects of specimen age and orientation. Am J Sports Med 19(3):217–225
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Halewood, C., Amis, A.A. Clinically relevant biomechanics of the knee capsule and ligaments. Knee Surg Sports Traumatol Arthrosc 23, 2789–2796 (2015). https://doi.org/10.1007/s00167-015-3594-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-015-3594-8