Pure Passive Hyperextension of the Human Cadaver Knee Generates Simultaneous Bicruciate Ligament Rupture

Abstract

Knee hyperextension has been described as a mechanism of isolated anterior cruciate ligament (ACL) tears, but clinical and experimental studies have produced contradictory results for the ligament injuries and the injury sequence caused by the hyperextension loading mechanism. The hypothesis of this study was that bicruciate ligament injuries would occur as a result of knee hyperextension by producing high tibio-femoral (TF) compressive forces that would cause anterior translation of the tibia to rupture the ACL, while joint extension would simultaneously induce rupture of the posterior cruciate ligament (PCL). Six human knees were loaded in hyperextension until gross injury, while bending moments and motions were recorded. Pressure sensitive film documented the magnitude and location of TF compressive forces. The peak bending moment at failure was 108 N m±46 N m at a total extension angle of 33.6 deg±11 deg. All joints failed by simultaneous ACL and PCL damages at the time of a sudden drop in the bending moment. High compressive forces were measured in the anterior compartments of the knee and likely produced the anterior tibial subluxation, which contributed to excessive tension in the ACL. The injury to the PCL at the same time may have been due to excessive extension of the joint. These data, and the comparisons with previous experimental studies, may help explain the mechanisms of knee ligament injury during hyperextension. Knowledge of forces and constraints that occur clinically could then help diagnose primary and secondary joint injuries following hyperextension of the human knee.