[Experimental capsulo-ligamentar lesions of the knee during passive hyperextension. Biomechanical aspects. A lesional evaluation and consequences].

PURPOSE OF THE STUDY: Passive hyperextension is a rare mechanism of injury of knee ligaments in clinical practice. The lesions are often complex and no consensus exists about their sequence. Our purpose was to study the mechanical behavior and the anatomical lesions of the knee following passive hyperextension until rupture.

MATERIAL AND METHODS: 12 pairs of fresh human cadaveric knees were tested after resection of soft tissue except for the ligaments and the Popliteus muscle. Some of them had specific ligaments sections (PCL or posterior capsule). We used a "four point bending" model at a constant rate (V = 3 10E-4 m/s) and measured failure torque and bending stiffness of the knee. Results were expressed as percent of the response of the normal contra lateral knee.

RESULTS: A wide range of absolute data was noted and correlated to the age and bone quality. Bony avulsion was constant. The posterior capsule was the first structure injured at an average of 23 degrees of recurvatum, followed by the posterolateral ligament. The PCL was the ultimate structure to fail at its femoral attachment, preceding complete dislocation of the knee. No ruptures of the ACL and medial collateral ligament were noted. After section of the posterior capsule, the stiffness of the knee decreased 40 to 80 percent compared to the normal opposite knee, whereas the isolated section of the PCL had no significant effect.

DISCUSSION: The method used in this study appears reliable. "The four point bending" is a reproducible model and the use of paired specimens allows a quantitative approach. The use of elderly specimens at a low strain rate in this experiment remains a questionable point. Passive hyperextension is characterized by automatic external rotation resulting in asymmetrical posterior lesions and tears of the PCL at its femoral attachment. On the contrary, active hyperextension of the knee can produce ACL injury by anterior translation of the tibia under the femur consecutive to Quadriceps femoris contraction.

CONCLUSION: Our experimental model is an effective and reproducible method to create passive hyperextension of the knee. The first structure to fail is the posterior capsule followed by the posterolateral ligament. The PCL is the ultimate structure to fail and no ACL rupture has been noted before dislocation.

CLINICAL RELEVANCE: if passive hyperextension mechanism is suspected, isolated posterior capsule lesion may occur and should be repaired. On the contrary, PCL tear should never be isolated and always associated with peripheral ligament injuries.