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A Clinically Relevant Assessment of Posterior Cruciate Ligament and Posterolateral Corner InjuriesEvaluation of Isolated and Combined Deficiency
Jon K. Sekiya, MD1; David R. Whiddon, MD2; Chad T. Zehms, MD2; Mark D. Miller, MD3
1 Department of Orthopaedic Surgery, MedSport, University of Michigan, 24 Frank Lloyd Wright Drive, P.O. Box 0391, Ann Arbor, MI 48106. E-mail address: sekiya@umich.edu
2 Bone and Joint/Sports Medicine Institute, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708
3 Department of Orthopaedics, University of Virginia, 400 Ray C. Hunt Drive, #330, Charlottesville, VA 22903
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the Navy Bureau of Medicine and Surgery, Washington, DC, Clinical Investigation Program (CIP# P04-0017) as well as cadaver donations worth less than $10,000 from the Musculoskeletal Transplant Foundation (MTF). In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Arthrex). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, the Department of the Navy, the Department of Defense, or the United States Government. Two authors (D.R.W. and C.T.Z.) are employees of the United States government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at the Bone and Joint/Sports Medicine Institute, Naval Medical Center Portsmouth, Portsmouth, Virginia

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Aug 01;90(8):1621-1627. doi: 10.2106/JBJS.G.01365
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Abstract

Background: The treatment of symptomatic posterior cruciate ligament injuries of the knee is controversial. Identification of concomitant injuries of the posterolateral corner is important to optimize surgical and clinical outcomes, although this diagnosis is sometimes difficult. The purpose of this study was to determine the physical examination and stress radiography parameters of isolated injuries of the posterior cruciate ligament and combined injuries of the posterior cruciate ligament and posterolateral corner. Our hypothesis was that Grade-3 posterior drawer laxity is an indicator of a concomitant injury of the posterolateral corner.

Methods: Ten pairs of cadaver knees (a total of twenty knees) were evaluated with posterior drawer testing, dial testing, and stress radiography. Stress radiography was performed by applying a 200-N posterior drawer at 90° of knee flexion. The knees were tested while intact and then retested following the sequential resection of the posterior cruciate ligament followed by the posterolateral corner structures.

Results: All intact specimens were rated as Grade 0 on posterior drawer testing. Sectioning of the posterior cruciate ligament resulted in Grade-2 posterior drawer in all specimens. The additional resection of the posterolateral corner resulted in Grade-3 posterior drawer in all specimens. Dial testing of the intact knees resulted in a mean (and standard error) of 10.5° ± 1.0° and 10.5° ± 0.80° of external rotation at 30° and 90°, respectively. This increased significantly to 15.1° ± 1.1° and 16.2° ± 0.89°, respectively, following sectioning of the posterior cruciate ligament (p < 0.05). After resection of the posterolateral corner, rotation was further increased to a mean of 21.6° ± 1.5° at 30° and 27.5° ± 1.6° at 90° (p < 0.05). On stress radiography, the average posterior displacements measured 2.9 ± 0.5 mm in the intact specimens, 12.7 ± 1.0 mm after resection of the posterior cruciate ligament, and 22.3 ± 1.6 mm after the additional resection of the posterolateral corner (p < 0.05). The corrected posterior displacement, calculated by subtracting the displacement in the intact knees, was 9.8 mm after resection of the posterior cruciate ligament and 19.4 mm after the additional resection of the posterolateral corner.

Conclusions: A grade of 3 on posterior drawer testing and >10 mm of posterior tibial translation on stress radiography correlate with the presence of a posterolateral corner injury in addition to a complete disruption of the posterior cruciate ligament.

Clinical Relevance: Detection of grade-3 posterior drawer on physical examination should alert the examiner to the presence of a posterolateral corner injury.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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