Functional Interaction of the Cruciate Ligaments, Posteromedial and Posterolateral Capsule, Oblique Popliteal Ligament, and Other Structures in Preventing Abnormal Knee Hyperextension
Authors: Noyes Frank R. , Clark Olivia , Nolan Joseph , Johnson Daniel J. 
Published: February 2023

Background: The ligaments and soft tissue capsular structures of the knee joint that provide a resisting force to prevent abnormal knee hyperextension have not been determined. This knowledge is required for the diagnosis and treatment of knee hyperextension abnormalities. Purpose: To determine the resisting moment of knee ligament and capsular structures that resist knee hyperextension. Hypothesis: The combined posteromedial and posterolateral capsular structures function to provide a major restraint to prevent abnormal knee hyperextension. The anterior and posterior cruciate ligaments resist knee hyperextension but function as secondary restraints. Study Design: Descriptive laboratory study. Methods: A 6 degrees of freedom robotic system determined intact laxity limits in 24 cadaveric knees from 0° to 100° of knee flexion for anteroposterior limits at ±135 N, abduction-adduction limits at ±7 N·m, and external-internal limits at ±5 N·m. One loading method (n = 14 knees) used a static loading sequence with knee hyperextension to 27-N·m torque while maintaining all other degrees of freedom at zero load during sequential soft tissue cutting. The second method (n = 10 knees) used a cyclic loading sequence to decrease viscoelastic effects with soft tissue cutting at 0° of extension, followed by knee hyperextension to 27-N·m torque and cycled back to 0°. Selective soft tissue cuttings were performed of the following: oblique popliteal ligament, fabellofibular ligament, posterolateral capsule, posteromedial capsule with posterior oblique ligament, cruciate ligaments, lateral collateral ligament, popliteus, anterolateral ligament and iliotibial band, and superficial plus deep medial collateral ligaments. The sequential loss in the restraining moment with sectioning provides the function of that structure in resisting knee hyperextension. Results: The median resisting force to knee hyperextension, in descending order, was the posteromedial capsule and posterior oblique ligament (21.7%), posterorolateral ligament and fabellofibular ligament (17.1%), anterior and posterior cruciate ligaments (13% and 12.9%, respectively), superior and deep medial collateral ligament (9.6%), oblique popliteal ligament (7.7%), and lateral collateral ligament (5.4%). The combined posterior capsular structures provided 54.7% and the anterior and posterior cruciate ligaments 25.3% of the total resisting moment to prevent knee hyperextension. Conclusion: Diagnosis of abnormal knee hyperextension involves a combination of multiple ligament and soft tissue structures without 1 primary restraint. The posteromedial and posterolateral capsular structures provided the major resisting moment to prevent knee hyperextension. The cruciate ligaments produced a lesser resisting moment to knee hyperextension. Clinical Relevance: This is the first study to comprehensively measure all of the knee ligaments and capsular structures providing a resisting moment to abnormal knee hyperextension. These data are required for diagnostic and treatment strategies on the pathomechanics of abnormal knee hyperextension in patients after injury or developmental cases.