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Importance of Tibial Slope for Stability of the Posterior Cruciate Ligament–Deficient Knee

J. Robert Giffin, MD^*, Kathryne J. Stabile, MD, MS, Thore Zantop, MD, Tracy M. Vogrin, MD, MS, Savio L-Y. Woo, PhD, DSc^|| and Christopher D. Harner, MD^#,¶

From the ^* Department of Orthopaedic Surgery, University of Western Ontario, London, Ontario, Canada, the Department of Orthopaedic Surgery, Wake Forest University, Winston-Salem, North Carolina, the Department of Trauma, Hand, and Reconstructive Surgery, Westfalische Wilhelms-University Münster, Münster, Germany, the Department of Emergency Medicine, Mercy Hospital of Pittsburgh, Pittsburgh, Pennsylvania, and the ^|| Department of Bioengineering and ^# Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania

^¶ Address correspondence to Christopher D. Harner, MD, UPMC Center for Sports Medicine, 3200 S. Water Street, Pittsburgh, PA 15203 (e-mail: harnercd{at}upmc.edu).

Background: Previous studies have shown that increasing tibial slope can shift the resting position of the tibia anteriorly. As a result, sagittal osteotomies that alter slope have recently been proposed for treatment of posterior cruciate ligament (PCL) injuries.

Hypotheses: Increasing tibial slope with an osteotomy shifts the resting position anteriorly in a PCL-deficient knee, thereby partially reducing the posterior tibial "sag" associated with PCL injury. This shift in resting position from the increased slope causes a decrease in posterior tibial translation compared with the PCL-deficient knee in response to posterior tibial and axial compressive loads.

Study Design: Controlled laboratory study.

Methods: Three knee conditions were tested with a robotic universal force-moment sensor testing system: intact, PCL-deficient, and PCL-deficient with increased tibial slope. Tibial slope was increased via a 5-mm anterior opening wedge osteotomy. Three external loading conditions were applied to each knee condition at 0°, 30°, 60°, 90°, and 120° of knee flexion: (1) 134-N anterior-posterior (A-P) tibial load, (2) 200-N axial compressive load, and (3) combined 134-N A-P and 200-N axial loads. For each loading condition, kinematics of the intact knee were recorded for the remaining 5 degrees of freedom (ie, A-P, medial-lateral, and proximal-distal translations, internal-external and varus-valgus rotations).

Results: Posterior cruciate ligament deficiency resulted in a posterior shift of the tibial resting position to 8.4 ± 2.6 mm at 90° compared with the intact knee. After osteotomy, tibial slope increased from 9.2° ± 1.0° in the intact knee to 13.8° ± 0.9°. This increase in slope reduced the posterior sag of the PCL-deficient knee, shifting the resting position anteriorly to 4.0 ± 2.0 mm at 90°. Under a 200-N axial compressive load with the osteotomy, an additional increase in anterior tibial translation to 2.7 ± 1.7 mm at 30° was observed. Under a 134-N A-P load, the osteotomy did not significantly affect total A-P translation when compared with the PCL-deficient knee. However, because of the anterior shift in resting position, there was a relative decrease in posterior tibial translation and increase in anterior tibial translation.

Conclusion: Increasing tibial slope in a PCL-deficient knee reduces tibial sag by shifting the resting position of the tibia anteriorly. This sag is even further reduced when the knee is subjected to axial compressive loads.

Clinical Relevance: These data suggest that increasing tibial slope may be beneficial for patients with PCL-deficient knees.

Key Words: knee • biomechanics • PCL • tibial slope

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