The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 4

Scientific Articles | April 01, 2009

Morphology of the Tibial Insertion of the Posterior Cruciate Ligament

Goro Tajima, MD, PhD¹; Masahiro Nozaki, MD²; Takanori Iriuchishima, MD, PhD³; Sheila J.M. Ingham, MD⁴; Wei Shen, MD, PhD⁴; Patrick Smolinski, PhD⁴; Freddie H. Fu, MD⁴

¹ Department of Orthopaedic Surgery, Iwate Medical University, 19-1 Uchimaru, Morioka 020-8505, Japan. E-mail address: gorot@iwate-med.ac.jp
² Department of Orthopaedic Surgery, Nagoya City University, 1 Kawasumi Nizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
³ Department of Orthopaedic Surgery, Surugadai Nihon University Hospital, 1-8-13 Surugadai, Kanda, Chiyoda-ku, Tokyo 101-8309, Japan
⁴ Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, 1010 Kaufmann Building, Pittsburgh, PA 15213. E-mail address for F.H. Fu: ffu@upmc.edu

View Disclosures and Other Information

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 Albert B. Ferguson, Jr., MD, Orthopaedic Fund of The Pittsburgh Foundation. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. 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.

Investigation performed at the Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Apr 01;91(4):859-866. doi: 10.2106/JBJS.H.00991

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Abstract

Background: It has been demonstrated that double-bundle reconstruction of the posterior cruciate ligament restores knee kinematics better than does single-bundle reconstruction. The objective of this study was to identify the tibial insertion site of the posterior cruciate ligament and the related osseous landmarks to help guide surgeons in the performance of an anatomical double-bundle reconstruction of the posterior cruciate ligament.

Methods: Twenty-one unpaired human cadaver knees were evaluated. The geometric data and surface features of the tibial insertion site of the posterior cruciate ligament and its bundles were studied with macroscopic observation and with three-dimensional laser photography.

Results: The mean surface areas (and standard deviations) of the anterolateral and posteromedial insertion sites were 93.1 ± 16.6 mm² and 150.8 ± 31.0 mm², respectively, and the distance between their centers was 8.2 ± 1.3 mm. The mean length and width of the anterolateral insertion site were 7.8 ± 1.5 mm and 9.2 ± 1.6 mm, and the mean length and width of the posteromedial insertion site were 9.4 ± 1.4 mm and 15.0 ± 2.7 mm. The average distances from the anterior and medial margins of the tibial plane to the center of the anterolateral insertion, defined as percentage ratios of the anteroposterior and mediolateral dimensions, were 83.4% ± 3.4% and 47.1% ± 1.9%, respectively, and the average distances from the anterior and medial margins of the tibial plane to the center of the posteromedial insertion were 95.5% ± 1.9% and 43.8% ± 2.2%. A notable change in angle, of >10°, was observed between the anterolateral and posteromedial slopes in sixteen of the twenty-one knees. The average angle between the anterolateral and posteromedial slopes was 14.5° ± 6.4°.

Conclusions: The tibial insertion site of the posterior cruciate ligament and its bundles is very complex. However, the shapes and positions of the insertion sites of the two bundles are consistent in that they are located in different planes on the posterior intercondylar fossa. We noted a consistent change in slope between the tibial insertion sites of the anterolateral and posteromedial bundles.

Clinical Relevance: The data from this study may improve our understanding of the anatomy of the posterior cruciate ligament attachments and may assist surgeons in performing reconstructive surgery in a more anatomical fashion.

Figures in this Article

Introduction

The posterior cruciate ligament has been described as the primary restraint to posterior tibial translation and as a secondary restraint to varus and valgus forces applied to the knee as well as to external rotation of the tibia¹. The ligament is composed of two functional bundles—the anterolateral bundle and the posteromedial bundle—which can be differentiated by their tension patterns and fiber orientations during knee motion^2,3. The posteromedial bundle becomes taut and resists posterior tibial translation during extension and hyperflexion, while the anterolateral bundle, which has a larger cross-sectional area, becomes taut and resists posterior tibial translation during mid-range knee flexion, when the posteromedial bundle is relaxed^2,3.

The treatment of a posterior cruciate ligament-deficient knee remains a controversial topic. Isolated or combined posterior cruciate ligament injuries can lead to pain, swelling, instability, and increased contact forces in the patellofemoral and medial compartments of the knee⁴. The results of operative treatment of posterior cruciate ligament injuries have not been as successful as those reported following anterior cruciate ligament reconstructions. The rate of success of conventional single-bundle reconstruction of the posterior cruciate ligament, the focus of which has been on recreation of the larger anterolateral bundle, has been variable, and knee osteoarthritis has been reported in 60% of patients after operative treatment⁵. Reconstructions of the anterolateral bundle are successful in restoring anteroposterior laxity in the flexed knee, but they may not completely restore normal knee kinematics⁶.

It has been demonstrated that double-bundle reconstruction of the posterior cruciate ligament, with which both the anterolateral and the posteromedial bundle are reconstructed, restores both normal knee kinematics and function better than does traditional single-bundle reconstruction^7-9. Although numerous authors have described the femoral insertion site of the posterior cruciate ligament^7-10, little has been mentioned about the tibial insertion site^6,11.

Double-bundle reconstructions of the posterior cruciate ligament are usually performed with use of the tibial inlay technique or the single-tibial-tunnel technique^12,13. The all-open or arthroscopically assisted tibial inlay techniques require a posterior approach to prevent surgical complications¹³. Recently, anatomical double-bundle reconstructions with a two-tibial-tunnel technique and all-arthroscopic tibial inlay techniques have also been described^14-16. To perform an anatomical double-bundle reconstruction with either of these new techniques, it is necessary to define the tibial insertion sites of both bundles. The aim of this study was to identify the tibial insertion site of the posterior cruciate ligament and the related osseous landmarks.

Materials and Methods

Specimen Preparation

Twenty-one fresh-frozen unpaired adult cadaver knees (nine from male donors and twelve from female donors), with no macroscopic degenerative or traumatic changes, were used in this study. The mean age of the donors at the time of death was 64.9 years (range, forty-two to ninety-three years).

Preparation began with the removal of all extra-articular soft tissue, followed by careful dissection through anterior and posterior approaches (Fig. 1-A). The lateral femoral condyle was cut off to expose the posterior cruciate ligament, and the synovial sleeve surrounding the posterior cruciate ligament was carefully removed (Fig. 1-B). The anterolateral and posteromedial bundles were identified by their different tension patterns that occur during the range of motion of the knee (Fig. 1-C). The insertion sites of the anterolateral and posteromedial bundles were outlined peripherally with use of fine pins, and all soft tissues were completely dissolved with use of a 10% sodium hydroxide solution for six hours. After removal of the soft tissues, an outline of the anterolateral and posteromedial bundles was made with a marker pen, and the bone morphology of the tibial insertion of the posterior cruciate ligament was observed grossly (Fig. 2).

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Fig. 1-A Fig. 1-B Fig. 1-C: Fig. 1-A through 1-C Posterolateral view of the left knee in 0° of extension (Fig. 1-A), illustration (courtesy of Mark A. Klingler) of the posterolateral view of the left knee in 90° of flexion after the lateral femoral condyle has been cut off (Fig. 1-B), and lateral view of the left knee in 0° of extension (Fig. 1-C), showing the anterolateral bundle (white arrow) and the posteromedial bundle (black arrow) of the posterior cruciate ligament and the posterior meniscofemoral ligament (pMFL).

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Fig. 2: Gross appearance of the posterior view of the left knee, showing the location of the tibial insertion site of the anterolateral bundle (ALB) and that of the posteromedial bundle (PMB) of the posterior cruciate ligament. The posterior cruciate ligament was found to be attached to the posterior intercondylar fossa between the tibial plateaus. The anterolateral bundle was attached to the superolateral aspect of the fossa. The posteromedial bundle was attached to the inferomedial aspect of the fossa, and an extensive portion of the posteromedial bundle was below the posterior part of the tibial rim.

Three-Dimensional Visualization and Measurements

The knees were scanned with use of a laser three-dimensional scanner (FARO Laser ScanArm V2; FARO Technologies, Lake Mary, Florida). The coordinates of the peripheries of the insertion sites were also recorded with use of the hard probe of the scanner. The accuracy of this measurement method (according to the manufacturer) is ±50 µm, and the repeatability is ±50 µm. The three-dimensional images were analyzed with specific software (Rapidform XOV and XOR, INUS Technology, Seoul, South Korea, and Geomagic Studio 9, Geomagic, Research Triangle Park, North Carolina) to obtain the three-dimensional anatomical measurements and visualization of the tibial insertion site of the posterior cruciate ligament and its bundles^10,17.

The three-dimensional measurements were analyzed on a tibial reference plane based on the morphology of the tibial plateau. First, the center regions of the medial and lateral tibial plateaus, with no curvatures, were selected by the reverse engineering software (Rapidform). Second, a plane was automatically fitted to the selected regions with use of the least-squares method^18,19 and was designated as the tibial plane. To measure the anteroposterior length and mediolateral width, a rectangle was fitted with use of the posterior condylar axis as a reference (Fig. 3), a method similar to a manual caliper measurement technique. The surface areas and slope angles of the anterolateral and posteromedial insertion sites were calculated, and the centers were defined as the centroids of their areas. The distance between these centers was also measured. The length and width of each insertion site were measured as a linear distance in perpendicular and parallel directions to the tibial plane passing through the insertion-site centers. To obtain geometric data, the centers were projected onto the tibial planes vertically and located by the anteroposterior, mediolateral, and vertical dimensions of the tibia. The locations of insertion-site centers were also defined as a percentage ratio of the anteroposterior and mediolateral dimensions.

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Fig. 3: Images made with three-dimensional laser photography, showing posterior and lateral views of the proximal part of the left tibia. The three-dimensional measurements were analyzed on a tibial reference plane based on the morphology of the tibial plateau.

Source of Funding

The authors received no external funding for this study. The authors received funding (less than $10,000) from the Albert B. Ferguson, Jr., MD, Orthopaedic Fund of The Pittsburgh Foundation.

Results

Three-Dimensional Measurements of the Tibial Insertion Sites of the Posterior Cruciate Ligament

The mean anteroposterior length of the tibial plane (and standard deviation) was 49.4 ± 6.1 mm, and the mean mediolateral width was 72.7 ± 6.5 mm.

The tibial insertion sites of the posterior cruciate ligament varied in size. The mean surface area of the entire insertion site of the posterior cruciate ligament was 243.9 ± 38.2 mm², with the insertion site of the anterolateral bundle being 93.1 ± 16.6 mm² and that of the posteromedial bundle being 150.8 ± 31.0 mm². The mean linear distance between the centers of the bundle insertion sites was 8.2 ± 1.3 mm. The mean length and width of the anterolateral bundle insertion site were 7.8 ± 1.5 mm and 9.2 ± 1.6 mm, respectively, and the mean length and width of the posteromedial bundle insertion site were 9.4 ± 1.4 mm and 15.0 ± 2.7 mm. These quantitative data are summarized in Table I.

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TABLE I Quantitative Measurements of the Tibial Attachment of the Posterior Cruciate Ligament and Its Landmarks

	Mean and Stand. Dev. (Range)
Surface area (mm²)
Posterior cruciate ligament	243.9 ± 38.2 (193.3-330.5)
Anterolateral insertion	93.1 ± 16.6 (68.0-128.1)
Posteromedial insertion	150.8 ± 31.0 (109.4-227.8)
Distance between centers of anterolateral and posteromedial insertions (mm)	8.2 ± 1.3 (5.5-10.6)
Length (mm)
Anterolateral insertion	7.8 ± 1.5 (4.9-10.3)
Posteromedial insertion	9.4 ± 1.4 (6.8-11.7)
Width (mm)
Anterolateral insertion	9.2 ± 1.6 (6.7-12.8)
Posteromedial insertion	15.0 ± 2.7 (11.2-20.0)
Change of slope (deg)	14.5 ± 6.4 (6.2-31.1)

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TABLE I Quantitative Measurements of the Tibial Attachment of the Posterior Cruciate Ligament and Its Landmarks

	Mean and Stand. Dev. (Range)
Surface area (mm²)
Posterior cruciate ligament	243.9 ± 38.2 (193.3-330.5)
Anterolateral insertion	93.1 ± 16.6 (68.0-128.1)
Posteromedial insertion	150.8 ± 31.0 (109.4-227.8)
Distance between centers of anterolateral and posteromedial insertions (mm)	8.2 ± 1.3 (5.5-10.6)
Length (mm)
Anterolateral insertion	7.8 ± 1.5 (4.9-10.3)
Posteromedial insertion	9.4 ± 1.4 (6.8-11.7)
Width (mm)
Anterolateral insertion	9.2 ± 1.6 (6.7-12.8)
Posteromedial insertion	15.0 ± 2.7 (11.2-20.0)
Change of slope (deg)	14.5 ± 6.4 (6.2-31.1)

The geometric data regarding the locations of the centers of the anterolateral and posteromedial bundle insertion sites are given in Table II.

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TABLE II Locations of the Centers of the Anterolateral and Posteromedial Insertions

	Mean and Stand. Dev. (Range)
	From Anterior Margin	From Medial Margin	From Tibial Plane
Anterolateral insertion
mm	41.3 ± 6.0 (31.5-55.0)	34.3 ± 3.6 (29.0-44.2)	1.5 ± 0.8 (0-2.7)
%	83.4* ± 3.4 (78.8-89.6)	47.1† ± 1.9 (43.1-52.2)
Posteromedial insertion
mm	47.1 ± 5.6 (39.1-59.5)	31.8 ± 3.2 (27.3-39.9)	6.0 ± 2.0 (3.0-9.4)
%	95.5* ± 1.9 (92.0-99.4)	43.8† ± 2.2 (40.0-48.1)

Defined as a percentage ratio of the anteroposterior dimension.Defined as a percentage ratio of the mediolateral dimension.

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TABLE II Locations of the Centers of the Anterolateral and Posteromedial Insertions

	Mean and Stand. Dev. (Range)
	From Anterior Margin	From Medial Margin	From Tibial Plane
Anterolateral insertion
mm	41.3 ± 6.0 (31.5-55.0)	34.3 ± 3.6 (29.0-44.2)	1.5 ± 0.8 (0-2.7)
%	83.4* ± 3.4 (78.8-89.6)	47.1† ± 1.9 (43.1-52.2)
Posteromedial insertion
mm	47.1 ± 5.6 (39.1-59.5)	31.8 ± 3.2 (27.3-39.9)	6.0 ± 2.0 (3.0-9.4)
%	95.5* ± 1.9 (92.0-99.4)	43.8† ± 2.2 (40.0-48.1)

Defined as a percentage ratio of the anteroposterior dimension.Defined as a percentage ratio of the mediolateral dimension.

Three-Dimensional Visualization of the Tibial Insertion Sites of the Posterior Cruciate Ligament

The geometry of the tibial insertion sites of the posterior cruciate ligament and its bundles was very complex; however, their shapes and positions were consistent in such a way that osseous landmarks for the anterolateral and posteromedial bundle insertion sites could be identified on the computed three-dimensional images.

The posterior cruciate ligament was attached to the posterior intercondylar fossa between the tibial plateaus, and it also extended below the posterior part of the tibial rim. This fossa was trapezoid-shaped and became wider inferiorly. The anterolateral bundle was attached to the superolateral aspect of the fossa, which was termed "anterolateral slope." The posteromedial bundle was attached to the inferomedial aspect of the fossa, which was termed "posteromedial slope," and an extensive portion of the posteromedial bundle was below the posterior part of the tibial rim (Fig. 4-A). A notable change in angle, of >10°, was observed between the anterolateral and the posteromedial slopes in sixteen of the twenty-one knees (Fig. 4-B). The average angle between the anterolateral and posteromedial slopes was 14.5° ± 6.4°.

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Fig. 4-A Fig. 4-B: Figs. 4-A and 4-B Images of the left knee made with three-dimensional laser photography (posterosuperior and posterolateral views), showing the insertion sites of the anterolateral and posteromedial bundles of the posterior cruciate ligament on the posterior intercondylar fossa. The small picture of the tibia in the upper right corner shows the orientation of the specimen. Fig. 4-A This fossa was trapezoid-shaped and became wider inferiorly. The anterolateral bundle was attached to the superolateral aspect of the fossa, which was termed "anterolateral slope," and the posteromedial bundle was attached to the inferomedial aspect of the fossa, which was termed "posteromedial slope." Fig. 4-B The two bundles were located in different planes in the posterior intercondylar fossa.

Discussion

The objective of this study was to identify and describe the tibial insertion site of the posterior cruciate ligament and the related osseous landmarks to assist surgeons in performing posterior cruciate ligament surgery in a more anatomical fashion.

The anatomy of the posterior cruciate ligament has been described by several authors^{2,3,10,11,20-24}. Girgis et al.² isolated, and described, the two primary components of the posterior cruciate ligament—i.e., the anterolateral and posteromedial portions. Although most studies have focused on the femoral insertion site of the posterior cruciate ligament¹⁰, we believe that the tibial insertion site is important and has been insufficiently studied. Gill et al.⁶ showed the importance of the tibial placement of the posterior cruciate ligament graft and its relationship to rotational inadequacies and suggested that the location of the tibial tunnel determines the effective moment arm of the posterior cruciate ligament graft forces relative to the applied loads. Furthermore, visualization of the tibial insertion site of the posterior cruciate ligament, based on accurate anatomical data, is important for successful arthroscopic reconstruction of the ligament. Insufficient visualization might cause neurovascular injuries, malpositioning of the tibial tunnel, and ultimately failure of the reconstruction²⁵.

We found that the average area of the posteromedial bundle insertion site was larger than that of the anterolateral bundle insertion site. This finding is similar to the observations by Takahashi et al.²³, who reported the areas of the anterolateral and posteromedial insertion sites to be 46.7 ± 15.6 mm² and 115.8 ± 54.6 mm², respectively. Using a digitizing system, Harner et al.²¹ found that the area of the anterolateral insertion site averaged 70 ± 26 mm² and that of the posteromedial insertion site averaged 62 ± 17 mm², and they did not observe a significant difference between the areas of the two sites. Edwards et al.²⁴, using simple photography (axial and posterior views), reported that the length and width of the anterolateral tibial insertion site averaged 8 ± 2 mm and 9 ± 2 mm, respectively, and the length and width of the posteromedial tibial insertion site averaged 6 ± 1 mm and 10 ± 2 mm. Amis et al.²⁰ described similar results in their report on the gross anatomy of the posterior cruciate ligament and its bundles, although they did not present specific measurements.

The differences between the sizes that we found and those reported in the literature might be due to the fact that we included all peripheral fibers of the posterior cruciate ligament, especially those of the posteromedial bundle, which were attached extensively to the distal tibial periosteum. Another difference might be due to our use of a more accurate measurement system—i.e., three-dimensional laser analysis. Our geometric data were similar to those recorded by Edwards et al.²⁴, who measured the locations on the basis of a line connecting the tibial plateau edges along the posterior condylar axis. However, their two-dimensional measurement methods cannot rule out the possibility of rotation or inclination, which may introduce an error. Our three-dimensional mapping measurement method has several advantages over previous techniques. These included analysis of bone morphology, with determination of the positions of the insertion sites within the complex osseous structure of the tibial plateau. We believe that these measurements will be a useful aid for judging guidewire position on fluoroscopy and for postoperative evaluation of the tunnel position on a computed tomographic or magnetic resonance imaging scan as well as for intraoperative determination of the tunnel position when a navigation system is used.

Another important finding that we noted was that the two bundles were located in different planes, with a change in slope between the tibial insertion sites of the anterolateral and posteromedial bundles. Sheps et al.¹¹ described the anatomical characteristics of the tibial insertion site of the posterior cruciate ligament with anatomical reference points and a simplified schematic diagram. Although they reported that the tibial insertion site of the posterior cruciate ligament and its bundles was very complex, they did not describe the three-dimensional characteristics of the posterior intercondylar fossa. However, it is important to note that these osseous landmarks are subtle structures related to the tibial insertion site of the posterior cruciate ligament. Sufficient arthroscopic visualization of the posterior cruciate ligament^26,27, careful probing, and removal of remnants of the posterior cruciate ligament are necessary to identify these osseous landmarks.

There were several limitations to our study. A comparatively small number of cadavers were investigated, and normal anatomical variation cannot be ruled out. Although an accurate three-dimensional measurement method was used, the accuracy of measurement was limited by the possibilities that the human dissection and subjective decisions regarding the insertion site could still introduce error.

In conclusion, the tibial insertion site of the posterior cruciate ligament and its bundles is very complex. However, the shapes and positions of the insertion sites are consistent with regard to the fact that the two bundles are located in different planes on the posterior intercondylar fossa and there is a change in slope between the anterolateral and posteromedial insertion sites. Image Not Available

Acknowledgements

Note: The authors thank Gulshan Sharma, PhD, and Andrew Holmes from the Department of Bioengineering of the University of Pittsburgh for their excellent technical assistance in this study. They also thank Monica Linde-Rosen, RN, BS, and Cesar Martins, MD, for their review of this paper and Mark A. Klingler for his artistic drawing.

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Topics

posterior cruciate ligament ; tibia

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Goro Tajima, Masahiro Nozaki, Takanori Iriuchishima, Sheila J.M. Ingham, Wei Shen, Patrick Smolinski, Freddie H. Fu; Morphology of the Tibial Insertion of the Posterior Cruciate Ligament. The Journal of Bone & Joint Surgery. 2009 Apr;91(4):859-866.

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