The spatial three-dimensional positional relationship between the posterior cruciate ligament tibial insertion and the posterior septum: an anatomical study

doi:10.21203/rs.3.rs-3099517/v1

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The spatial three-dimensional positional relationship between the posterior cruciate ligament tibial insertion and the posterior septum: an anatomical study

https://doi.org/10.21203/rs.3.rs-3099517/v1

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Background

The posterior cruciate ligament (PCL) tibial insertion and posterior septum are important factors affecting the success rate of posterior cruciate ligament reconstruction(PCLR). The purpose of this study was to accurately quantify the anatomical features and relationship of the PCL tibial insertion and posterior septum.

Methods

Twelve cadaveric human knees were dissected to investigate the PCL and posterior septum. First, the anatomical localization of the PCL, tibial insertion and posterior septum were observed from the medial and lateral sides of the knee joint using a U-shaped capsulotomy. Second, the border length and insertion of the PCL tibial insertion were measured with a soft ruler, and a tibial tunnel was created within the anatomical footprint of the PCL while preserving the integrity of the posterior septum, and the ratio of tunnel exit to PCL tibial insertion was calculated. Finally, HE staining was performed to evaluation the blood vessels content in the posterior septum.

Results

The PCL and its tibial insertion were located medial to the posterior septum in all specimens, and the inferior border of the inserion is adjacent to the posterior capsule reflexion and above the shipboard-like structure. The PCL tibial insertion had a right-angle trapezoidal-like structure with narrow superior and wide inferior sides. The superior and inferior sides of the insertion were approximately (8.8 ± 1.7) and (13.4 ± 3.2) mm, respectively, and the medial and lateral sides were approximately (11.5 ± 1.2) and (12.1 ± 0.3) mm, with an area of approximately (123.3 ± 31.4) mm². Compared to the posterior capsule, the posterior septum contained abundant blood vessels.

Conclusion

The PCL in the posterior compartment of the knee follows the posterior septum and is located entirely medial to the posterior septum, and the inferior border of the PCL tibial inserion is adjacent to the posterior capsule reflexion and above the shipboard-like structure. It is feasible to create an effective tibial tunnel within the tibial footprint of the PCL while preserving the posterior septum.

PCL

posterior septum

tibial tunnel

anatomy

The posterior cruciate ligament (PCL) is an important structure for maintaining knee stability. Most PCL injuries are high-energy injuries[1], which usually occur in traffic accidents, strenuous sports or highly confrontational sports (such as football, skiing, etc.), and are often accompanied by serious axial and rotational instability of the knee joint[2, 3]. Currently, posterior cruciate ligament reconstruction (PCLR) is preferred for PCL injuries above degree Ⅱ to restore knee stability[4]. At present, many scholars have conducted a large number of clinical studies on the graft types, reconstruction methods, "Killer Turn" and other factors of PCLR, but PCLR still has a high failure rate[5–7]. The author believes that in addition to the above-mentioned reasons, whether the blood flow around the tibial insertion after PCLR is destroyed is also a nonnegligible factor.

The PCL tibial insertion is located behind the intercondylar crest of the tibia, which is an irregular quadrilateral shape with a narrow superior and wide inferior sides[8]. It is highly concealed and is surrounded by important tissues such as posterior septum, posterior capsule, popliteal artery and vein, nerve and blood vessels, etc[9–11]. Therefore, it brings great challenges for many novices to observe and locate tibial insertion under arthroscopy[12, 13]. In order to achieve a better arthroscopic view to avoid complications of neurovascular injury, many operators remove the posterior septum, PCL remnant, and partial posterior capsule structures during PCLR, which may adversely affect the healing blood flow of the PCLR graft[14]. The posterior septum is a continuous anterior to posterior structure in the posterior lateral compartment that is connected anteriorly to the fat pad, pterygoid folds, or mucosal ligaments and medially between the anterior and posterior cruciate ligaments, and consists of connective tissue, fat, and synovial membranes containing abundant neurovascular tissue and a large number of type II and type IV mechanoreceptors[15]. Ramos et al. found that the middle genicular artery divides from the popliteal artery and enters the posterior septum to form a vascular network that provides the PCL provides the main source of blood flow[16]. Therefore, preserving the posterior septum during PCLR can better promote recovery of graft blood vessels.

At present, there are many studies on the anatomy of the PCL tibial insertion, but there are few studies on the adjacency between the PCL tibial insertion and the surrounding soft tissues, especially the spatial position relationship between PCL tibial insertion and the posterior septum. In addition, more studies have been performed on PCLR or PCL tibial insertion avulsion fracture repositioning with arthroscopic trans-septum approach, which makes many surgeons uncertain about whether the posterior septum can be preserved in PCLR surgery. The present study was designed to investigate the three-dimensional spatial anatomy of the PCL and posterior septum through anatomy, hoping to provide a basis for completing PCLR while preserving the intact posterior septum.

Source and selection of specimens

Twelve fresh frozen, unpaired adult cadaveric knees (8 male, 4 female; 7 left knee, 5 right knee) with a mean age of 49.75 ± 3.54 years (43 to 57) were dissected in the anatomy teaching and research laboratory of Hebei Medical University from 2023.03 to 2023.06, and the study was reviewed by the ethical review committee of Hebei Medical University (ethics no: 2022002). None of the corpse specimens were treated with formalin immersion, the knee joint had no history of surgical treatment, and the capsule and intracapsular structure were undamaged.

Separation and observation of PCL and posterior septum

The cadaver was fresh frozen at -20°C and thawed overnight prior, placed prone on the anatomical table, and an S-shaped incision of approximately 25 cm above and below the joint line, along which the skin and subcutaneous fat layer were incised in turn to expose the popliteal artery, tibial nerve and other neurovascular tissues layer by layer, and the popliteal artery and its branches were dissected after direct observation, and finally the medial and lateral heads of the gastrocnemius muscle and toe muscle were opened to expose the capsule. An inverted U-shaped incision was made 5 cm above the medial and lateral femoral condyles[17], and the capsule was carefully opened from superior to inferior to expose the PCL, meniscofemoral ligament (MFL) and posterior septum and other intra-articular structures. After observing the tissue morphology of PCL and posterior septum, the anatomic relationship between PCL and posterior septum and MFL was observed from the medial and lateral knee joints, respectively. The geometry of the PCL tibial insertion and its anatomical positioning in relation to the posterior septum were observed, and the center of the PCL tibial insertion (point C) and the center of the tibial tunnel (point S) were measured horizontally and vertically from the joint surface of the posterior septum and medial and lateral tibial plateau articular surfaces, respectively, using a soft ruler. Finally, the angle between the posterior septum and the articular surface of the lateral tibial plateau was measured using a protractor.

Histological analysis

All of posterior septum and posterior capsule tissue specimens obtained from the dissection were unfolded as far as possible, and the specimens were divided into 3×3 zones of uniform sized areas using a tissue dissecting knife, and the separated specimens were subjected to tissue sectioning and HE staining. Finally, the stained sections were placed under 4×10 and 10×10 optical microscopes successively and the extent and main distribution area of blood vessels in posterior septum and posterior capsule were observed.

Statistical analysis

A one-way repeated measures ANOVA was used to compare the distances between the C and S points and the distances from the articular surface of the tibial plateau and the posterior septum, respectively. Paired Student’s t-tests were used to compare the lengths of the four lateral sides of the PCL tibial insertion and the insertion area. Differences were considered statistically significant when P < 0.05.

Anatomical localization relationship of PCL and posterior septum

From both sides of the knee joint to observe the medial and lateral compartments after U-shaped capsulotomy. First, it was observed that a large amount of adipose tissue was observed attached to the posterior septum, and several vascular tissues were distributed inside the septum, anteriorly facing the posterior border of the PCL and the superior border of the femoral intercondylar fossa, and the bottom was connected to the posterior capsule, and the whole stood in a curtain-like shape in the center of the articular cavity and separated the medial and lateral compartments. The shiny white fibrous structure of the PCL was observed in the posterior medial compartment (yellow ball), and its overall structure was located medial to the posterior septum and the integrity of the septum was not disrupted (green ball). The MFL (purple ball) accompanied the PCL superiorly and ended at the medial femoral condyle (Fig. 1).

The muscle beneath the posterior capsule reflexion was cleared with a periosteal stripper, and a shipboard-like curved bony structure without muscle or tendon attachment was observed beneath it (Fig. 2). The geometry of the PCL tibial insertion, which was mainly located medial to the mid-axis of the tibial plateau, was a right-angle trapezoidal-like structure with narrow superior and wide inferior sides (Fig. 3), and the superior and inferior edges of the insertion were adjacent to the posterior root of the medial meniscus and the tibial retroflexion of the posterior capsule, respectively, with a near-parallel alignment between them, approximately (8.8 ± 1.7) and (13.4 ± 3.2) mm, respectively. The insertion is located medially just posterior to the medial tibial intercondylar crest and runs slightly perpendicular to the tibial plateau, approximately (11.5 ± 1.2) mm, and the insertion runs immediately lateral to the posterior septum, with no obvious tissue gap seen between them, approximately (12.1 ± 0.3) mm. Finally, In all 12 specimens, only the fat and synovial tissue of the septum was observed on the lateral side of the septum, and no PCL was observed in the articular cavity, as well as a blue ball wrapped in synovial membrane to locate the lateral border of the PCL at the tibial end, while the integrity of the posterior septum was not disrupted(Fig. 4).

The area of the PCL tibial insertion was measured to be approximately (123.3 ± 31.4) mm² in twelve knee specimens. An 8 mm diameter drill was selected for the creation of the tibial tunnel, and the posterior septum were not damaged during the creation of the tunnel, which was calculated to have an exit area of approximately 50.2 mm², accounting for approximately 32.4–54.6% of the tibial insertion area. Finally, after marking the point C and point S with a marking needle, the straight-line distance between them was measured by a soft ruler as (4.8 ± 0.9) mm, the horizontal vertical distance as (1.4 ± 0.1) and (3.7 ± 0.7) mm, and then the horizontal line of the tibial plateau and the posterior septum were marked with a signal pen, and the distance of point C from the tibial plateau was measured by a soft ruler as (5.3 ± 0.5) mm from the articular surface, and the horizontal and vertical distances from the posterior septum were approximately (7.5 ± 0.8) and (6.5 ± 0.5) mm, respectively; the S points were (9.3 ± 1.2), (6.7 ± 2.9), and (5.7 ± 2.3) mm from the three landmark, and the angle made by the posterior septum with the articular surface of the lateral tibial plateau was approximately (59.5 ± 5.0)°.

Histological study

After taking fresh specimens of the posterior septum and posterior capsule for 3×3 tissue sectioning and HE staining, they were successively placed under 4×10 and 10×10 magnification microscopes for observation, and under the 4×10 magnification microscope, it was found that in the posterior capsule section, only apparently continuous vascular tissue could be observed in the middle region of the section, and little or no vascular tissue could be seen in the surrounding region of the section, while a large amount of vascular tissue was distributed within the posterior septum sections, mainly in the middle and upper regions of the septum. It is noteworthy that the vascular tissue in the bottom of the posterior septum had more vascular distribution compared with the posterior capsule (Fig. 5). On the other hand, under a 10×10 magnification microscope, the vascular structures in the posterior septum were clearly visible and distributed in a continuous pattern, while only a large number of collagen structures with a small amount of vascular tissue were visible in the capsule tissue section (Fig. 6).

The most important finding of this study was the confirmation on cadaveric specimens that the PCL and its tibial insertion were always located medial to the posterior septum and that it was possible to create an effective tibial tunnel in the anatomical footprint of the PCL while preserving the posterior septum. In addition, the anatomical morphology of the PCL tibial insertion was found to be right-angle trapezoidal-like, and the length of the four lateral sides of the PCL tibial insertion and the area of the insertion were measured on twelve human cadaveric knee.

To date, there is no consensus on the description of the anatomical morphology of the PCL tibial insertion[18]. Sheps et al. performed anatomical experiments on 10 knee specimens from 12 cadavers and found that the PCL tibial insertion showed a trapezoid-like structure, located in the depression between the tibial plateau and extending below the articular surface, with the superior lateral and superior medial angles of the insertion located in an oblique walking shape between the anterior angles of the medial and lateral menisci, with palpable ship side sample structure represents the inferior boundary[19]. Ramos et al. found a right-angle trapezoidal-like structure in the center of the PCL tibial insertion after dissecting 30 knees, with the superior and inferior lateral edges of the insertion parallel and perpendicular to the medial side, the lateral oblique walk of the insertion, and the posterior lateral edge at a distance of 1.7 mm from the posterior capsule[17]. Our results about the morphology of the insertion are similar to those of Sheps and Ramos et al. The PCL tibial insertion region has a right-angle trapezoidal-like structure with a narrow superior and a wide inferior border. In addition, for the description of the inferior border of the insertion, our findings were similar to those of Winkler et al, which found that the tibial footprint is bounded posteriorly by the champagne-glass drop-of, a bony landmark at the transitional zone to the popliteus muscle, just was the posterior capsule tibial retroflexion[20]. Therefore, we believe that the PCL tibial footprint is always located above the shipboard-like structure and does not extend further down.

The current literature on the anatomical location of the PCL and its tibial insertion and posterior septum is infrequent. Ahn et al. found that within the posterior articular cavity, the posterior septum separates the medial and lateral compartments of the knee, while the PCL is always located medial to the posterior septum[21]. Luo et al. described the alignment of the posterior septum in relation to the PCL tibial insertion after dissecting 22 knees, with the posterior septum wrapping around the lateral border of the PCL in 8 specimens and anterior to the PCL in another 14 specimens, the posterior septum wrapped around the PCL after bifurcation, and both alignments ended at the posterior capsule[22]. Unfortunately, neither Ahn et al. nor Luo et al. simultaneously explored the anatomical relationship of the PCL and its tibial insertion with the posterior septum. First, within the articular cavity, we are in agreement with Ahn et al. that the PCL is always located medial to the posterior septum, however, at the PCL tibial insertion, we found only 1 alignment relationship where the posterior septum was bypassed from the lateral side of the PCL in all 12 specimens compared to the 2 alignment relationships described by Luo et al. We believe that this difference in alignment may be due to the fact that Luo et al. first cleaned the posterior septum before determining the positioning of the tibial insertion and posterior septum, rather than directly observing the anatomic relationship from the medial and lateral views of the knee, thus confusing the tissue distribution of the lateral border of the insertion and the posterior septum and eventually appearing as two alignments.

In addition, the area of the footprint of the PCL tibial insertion was measured to be approximately (123.3 ± 31.4) mm², and the horizontal and vertical distances of the point S from the posterior septum were approximately (6.7 ± 2.9) and (5.7 ± 2.3) mm, respectively, which is similar to the findings of Greiner et al, who measured the surface area of the tibial insertion to be approximately 155 mm² after dissecting 10 knee specimens[23]. The 8 mm diameter tibial tunnel outlet selected for this study accounted for approximately 30.0–52.2% of the tibial insertion area, whereas when a 9 mm diameter tunnel was selected, it accounted for approximately 38.0–66.1% of the insertion area, and even when a 10.0 mm diameter tunnel was selected, it accounted for only 46.9–81.56%. Therefore, we believe that it is perfectly feasible to create an 8 to 10 mm diameter tibial tunnel within the PCL tibial footprint while preserving the integrity of the posterior septum, although it is worth noting that when the graft diameter is 11 mm, there is a risk of damaging the posterior septum by creating a tunnel centered on point C.

The preservation of the posterior septum during PCLR can help in the recovery of the physiological function of the knee after ligament surgery. Ramos et al. found that the vascular network formed by the middle genicular artery entering the posterior septum after division of the popliteal artery is mainly concentrated in the superior region of the septum, and therefore the intraoperative preservation of this region can prevent the recovery of blood flow after PCLR[16]. Our findings are similar to those of Ramos, in that the dissection revealed that the middle genicular artery branches from the popliteal artery above the popliteal fossa and penetrates deep into the posterior septum to supply blood, and HE staining of the posterior septum and capsule tissues revealed that not only the upper and middle regions of the posterior septum, but also the tissue at the base of the posterior septum is still rich in blood vessel tissue, suggesting that preserving the integrity of the base of posterior septum also has the potential to promote the recovery of blood vessel after PCLR, compared to the trans-septum approach[24]. In addition, the posterior septum contains a large number of type II and type IV mechanoreceptors, and the neurosensory deficits associated with the loss of proprioceptors can be effectively reduced by preserving the posterior septum during PCLR[25]. Konrads et al. followed up 21 patients with intraoperative preservation of the posterior septum from 6 to 12 months, and at the last follow-up, all patients had no joint effusion, 90.5% of patients had a complete return to preoperative level of joint motion, and the mean difference in tibial posterior displacement on stress radiographs was 4.1 mm on the healthy and affected side[26]. This suggests that the posterior septum contains rich hemodynamic tissues that can help accelerate the rehabilitation process and efficiency of PCLR.

There are several limitations on the anatomy study. First, PCLR tibial tunnel creation was performed on a cadaveric anatomical basis, which is somewhat different from the actual clinical arthroscopic observation, but the specimens included were freshly frozen with intact intra-articular structures, and the experimental data measured were close to those of general clinical patients, and therefore have reference significance for clinical arthroscopic PCLR. Second, the number of specimens included in the study was only 12, but the average age of the included specimens was (49.75 ± 3.54) years, which was mainly in middle age, and no significant degeneration of intra-articular ligaments and other structures was observed after opening the capsule, which is generally representative. Third, we found the area of PCL tibial insertion measured in the study was (123.3 ± 31.4) mm², which is smaller than the area of the insertion reported in other literature, which may be related to the Asian ethnicity to which the specimens belong.

In conclusion, the posterior septum stands in a curtain-like shape in the posterior central part of the knee and separates the medial and lateral compartments, and its base is connected to the posterior capsule, both within the articular cavity and at the PCL tibial insertion, where the PCL follows and lies completely medial to the posterior septum. In addition, the PCL tibial insertion has a right-angle trapezoidal structure with an area of approximately (131.7 ± 35.6) mm², so it is feasible to create a tibial tunnel of 8–10 mm in diameter within the PCL tibial footprint while preserving the integrity of the posterior septum.

Availability of data and materials

The data analyzed in this study were taken from anatomy study, which can be found from Pubmed.

Acknowledgements

The authors are grateful to the Hebei Medical University for providing the specimen.

Authors’ contributions

ZC conceived and designed the study. LPJ, ZKL, ZQS,YZN, SMTand YG participated in the data analysis. ZC and JTD drafted the manuscript. JTD revised the manuscript. Final manuscript was read and approved by all authors.

Funding

This study was supported by the National Natural Science Foundation of China (No. 82172460) , Natural Science Foundation of Hebei Province (No.H2020206562), “14th Five-Year” clinical medicine Innovation Research Team Support program of Hebei Medical University(2022LCTD-B25), Leader of the outstanding clinical medical talents training project funded by Hebei Provincial government in 2022 ( project name: Mechanism of secondary osteoarthritis after anterior cruciate ligament reconstruction) and Science and Technology Department of Hebei Province assisted Xinjiang science and technology plan project (project name: Biological and kinematic study on accurate localization of tibial soft reference in posterior cruciate ligament reconstruction).

Ethics approval and consent to participate

This study was approved by the ethical review committee of Hebei Medical University (ethics no: 2022002).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflicts of interest.

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No competing interests reported.

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You are reading this latest preprint version

The spatial three-dimensional positional relationship between the posterior cruciate ligament tibial insertion and the posterior septum: an anatomical study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Source and selection of specimens

Separation and observation of PCL and posterior septum

Histological analysis

Statistical analysis

Results

Anatomical localization relationship of PCL and posterior septum

Histological study

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1