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PubMedDate not supplied

MR imaging of the normal ligaments and tendons of the ankle.

The 10 major ligaments and nine major tendons of the ankle were evaluated in 17 ankle MR studies to determine the incidence of visualization of each structure in each of the three orthogonal planes. High-resolution technique was used, with 3 mm slice thickness and an in-plane resolution of 0.6 mm. Of the 19 ligaments and tendons evaluated, 18 demonstrated more than 70% frequency of visualization in at least one imaging plane. However, seven ligaments and three tendons demonstrated 0% visualization in at least one of the three orthogonal planes. Seven ligaments showed more than 70% visualization in only one plane (three coronal, two axial, two sagittal). Only the Achilles tendon and anterior tibial tendon demonstrated 100% visualization in all three planes. We conclude that all three orthogonal planes are essential to achieve optimal visualization of all of the major ligaments and tendons of the ankle. For specific evaluation of selected ligaments or tendons, only one or two planes may be required.

Achilles Tendon↗
PubMedDate not supplied

MRI versus lateral stress radiography in acute lateral ankle ligament injuries.

PURPOSE: Our goal was to compare the abilities of MRI and stress radiography to detect the extent of recent lateral ankle ligament inversion injuries. METHOD: In this prospective study, 60 athletically active patients (aged 18-45 years) with recent inversion trauma (< or = 7 days) underwent stress radiography and MRI. In 15 patients, the MR findings were reviewed at surgery. Patients were divided into three groups according to severity of ligament injury on MRI (no, one, or two to three ligament tears). Based on bilateral stress radiography, patients were classified into three groups according to the differential degree of talar tilt (< or = 5, 6-14, or > or = 15 degrees) and compared with patients from the MR groups. RESULTS: Surgery showed MRI to have 74% sensitivity and 100% specificity in the evaluation of complete lateral ankle ligament tears. Agreement between MR and stress radiography groups for the severity of recent lateral ankle ligament tears was poor (kappa = 0.030). CONCLUSION: MRI should be performed in young, athletically active patients if surgical intervention is contemplated, especially at 6-14 degrees talar tilt on stress radiography, since stress radiography tends to over- and underestimate the severity of lateral ligament trauma.

Acute Disease↗
PubMed1996

Injuries involving the transverse atlantal ligament: classification and treatment guidelines based upon experience with 39 injuries.

Comprehensive anatomic and clinical analyses of 39 patients with injuries involving the transverse atlantal ligament or its osseous insertions were performed to assess the morphology of the injured ligaments and the patients' capacity to heal. Injuries of the upper cervical spine were screened with plain radiographs, thin-section computed tomography, and magnetic resonance imaging studies. The injuries were classified as disruptions of the substance of the ligament (Type I injuries, n = 16) or as fractures and avulsions involving the tubercle for insertion of the transverse ligament on the C1 lateral mass (Type II injuries, n = 23). These two types of injuries had distinctly different clinical characteristics that were useful for determining treatment. Type I injuries were incapable of healing satisfactorily without internal fixation; they should be treated with early surgery. Type II injuries, which rendered the transverse ligament physiologically incompetent even though the ligament substance was not torn, should be treated initially with a rigid cervical orthosis, because they had a 74% success rate nonoperatively. Surgery should be reserved for patients with Type II injuries that have nonunion with persistent instability after 3 to 4 months of immobilization. Type II injuries had a 26% rate of failure of immobilization; therefore, close monitoring is needed to detect patients who will require delayed operative intervention.

Adolescent↗
PubMed1995

Inframammary crease ligament.

This study was designed to clarify and define the anatomic components of the inframammary crease in the female breast. Thirteen blunt dissections of the female breast were performed in cadavers and one dissection was performed in a living patient undergoing mastectomy. During the course of these dissections, a ligament was identified. This ligament originates from the fifth rib periosteum medially and the fascia between the fifth and sixth ribs laterally. The ligament inserts distally into the deep dermis of the inframammary skin fold. Histologic sections confirmed the proximal bony origin of this structure. In three cadavers, the contralateral breast was studied as it pertains to transaxillary subpectoral mammaplasty using the Agis-Dingman dissector (Padgett Instruments, Kansas City, Mo.). If too forceful a sweep were made in the inferior portion of the dissection, the ligament would be disrupted. This separation of the ligament from its origin could lead to the "double-bubble" phenomenon. Further, the horizontal position of this ligament determines the medial versus lateral fall of the ptotic breast.

Breast↗
PubMed1987

Cervical ligamentous instability in a canine in vivo model.

A canine in vivo model of midcervical ligamentous instability was developed by dividing the anterior longitudinal ligament, anulus fibrosus, and all posterior ligamentous structures including the ligamentum flavum. The natural history of healing in the model, the effect on its healing by an adjacent one-level arthrodesis, and the effect of a one-level arthrodesis on normal adjacent ligamentous structures were studied radiographically, mechanically, and histologically. The authors determined that healing takes place primarily by anterior scar formation in their instability model but not to a degree sufficient to recreate normal mechanical stability. After three months, healing in the model was not affected by an adjacent arthrodesis; however, acutely, instability apparently was increased as three animals became quadriplegic between the second and fourth postoperative days. Arthrodesis did not affect adjacent normal ligamentous structures, during this period. Incomplete healing in the authors' model supports those who advocate arthrodesis as the treatment of choice for destabilizing cervical ligamentous injury. The authors previously reported the case of a patient who sustained bilateral facet dislocations adjacent to an arthrodesed segment and questioned whether this resulted from a stress-concentrating effect. This study indicates that this could well have been the case acutely. Thus, inadvertent exclusion of an unstable segment from an arthrodesis has potentially catastrophic results. Finally, the authors also have previously questioned whether arthrodesis of a midcervical segment could lead to instability of adjacent normal segments. This project does not support such a concern, at least for the three postoperative months of study.

Animals↗
PubMed1991

Genetic study of ossification of the posterior longitudinal ligament in the cervical spine with human leukocyte antigen haplotype.

To evaluate the genetic background of ossification of the posterior longitudinal ligament, the relationship between the presence of absence of ossification and human leukocyte antigen haplotypes was studied in 33 families of patients with ossification of the posterior longitudinal ligament. The study revealed that human leukocyte antigen haplotypes formed certain types of clusters, and that some human leukocyte antigen haplotypes were very rare in the Japanese population, suggesting the involvement of human leukocyte antigen-linked factors in the pathogenesis of ossification of the posterior longitudinal ligament of the cervical spine. In the families of these patients, ossification of the posterior longitudinal ligament was demonstrated by radiography in 56% (10/18) of the siblings. Each of these siblings shared both human leukocyte antigen haplotypes with the patient. None of those who shared only one human leukocyte antigen haplotype with the patient had developed ossification of the posterior longitudinal ligament. From these findings, the presence of both pathogenic human leukocyte antigen haplotypes is considered to be necessary for the development of ossification of the posterior longitudinal ligament, and this genetic predisposition may be activated by multiple factors, including regressive degeneration due to aging and the environment.

Cervical Vertebrae↗
PubMed1994

Transverse atlantal ligament disruption associated with odontoid fractures.

OBJECTIVES: The authors evaluated transverse atlantal ligament integrity in patients with fractures of the odontoid process of the axis. SUMMARY OF BACKGROUND DATA: Injuries of the transverse atlantal ligament can result in atlantoaxial instability after fractures of the atlas or axis, even if osseous healing occurs. METHODS: The clinical histories and follow-up examinations and radiographic data of 30 patients with odontoid fractures were reviewed, using a combination of magnetic resonance (MR) imaging, thin-cut computed tomography (CT), and plain radiographs to evaluate osseous and ligamentous injuries. RESULTS AND CONCLUSIONS: Osteoperiosteal ligamentous avulsion injuries were identified on MR imaging in three patients and were associated with acute and delayed instability and nonunion. The combination of MR imaging, CT, and plain radiographs is useful in evaluating unstable odontoid fractures to facilitate rational treatment planning. Odontoid fractures with transverse ligament injuries should be considered for early surgical stabilization because this combination of injuries is unlikely to heal nonoperatively. Anterior odontoid screw fixation should be avoided when the ligament is injured.

Adolescent↗
PubMed1995

Role of ligaments and facets in lumbar spinal stability.

STUDY DESIGN: The issue of segmental stability using finite element analysis was studied. Effect of ligament and facet (total and partial) removal and their geometry on segment response were studied from the viewpoint of stability. OBJECTIVES: To predict factors that may be linked to the cause of rotational instabilities, spondylolisthesis, retrospondylolisthesis, and stenosis. SUMMARY OF BACKGROUND DATA: The study provides a comprehensive study on the role of facets and ligaments and their geometry in preserving segmental stability. No previous biomechanical study has explored these issues in detail. METHODS: Three-dimensional nonlinear finite element analysis was performed on L3-L4 motion segments, with and without posterior elements (ligaments and facets), subjected to sagittal moments. Effects of ligament and facet (partial and total) removal and their orientations on segment response are examined from the viewpoint of stability. RESULTS: Ligaments play an important role in resisting flexion rotation and posterior shear whereas facets are mainly responsible for preventing large extension rotation and anterior displacement. Facet loads and stresses are high under large extension and anterior shear loading. Unlike total facetectomy, selective removal of facets does not compromise segmental stability. Facet loads are dependent on spatial orientation. CONCLUSIONS: Rotational instability in flexion or posterior displacement (retrospondylolisthesis) is unlikely without prior damage of ligaments, whereas instability in extension rotation or forward displacement (spondylolisthesis) is unlikely before facet degeneration or removal. The facet stress and displacement distribution predicts that facet osteoarthritis or hypertrophy leading to spinal stenosis is most likely under flexion-anterior shear loading. Selective facetectomy may restore spinal canal size without compromising the stability of the segment. A facet that is more sagittally oriented may be linked to the cause of spondylolisthesis, whereas a less transversely oriented facet joint may be linked to rotational instabilities in extension.

Biomechanical Phenomena↗
PubMed1995

Dually innervating nociceptive networks in the rat lumbar posterior longitudinal ligaments.

STUDY DESIGN: The present study investigated the distribution of sensory and autonomic nerves to the posterior longitudinal ligament of the rat lumbar vertebra. OBJECTIVE: The results were analyzed to provide a new insight into the pathogenesis of low back pain. SUMMARY OF BACKGROUND DATA: Previous studies that have descriptively reported on posterior longitudinal ligament innervation have attributed important roles to the sinuvertebral nerve as an output of nociceptive sensation. Meanwhile, development of immunohistochemistry has made it possible to identify numerous neurotransmitters, and thus various suggested pathophysiologic roles of the nerve fibers in the posterior longitudinal ligament. However, such microscopic identification of the nerve fibers has not been able to reveal comprehensive distributions of the various fibers, which are presumed to be derived from the sinuvertebral nerve. METHODS: Rat posterior longitudinal ligaments of whole thickness was immunohistochemically stained for calcitonin gene-related peptide and tyrosine hydroxylase, which have been considered markers of nociceptive and noradrenergic fibers respectively. Light-microscopic and electron-microscopic observation was reinforced with another experimental study in which resection of the dorsal root ganglia induced characteristic denervation patterns to the rat posterior longitudinal ligament. RESULTS: The present study revealed that the lumbar. PLL was dually innervated by two distinctive systems of nociceptive fibers. One of the systems was polysegmentally innervated and closely associated with autonomic innervation, whereas the other was unisegmentally innervated and not associated with autonomic fibers. CONCLUSION: Pathogenesis of low back pain can be better understood if the presence of the two distinctive nerve systems innervating the posterior longitudinal ligament is taken into account.

Animals↗
PubMed1996

Effects of strain distribution in the intervertebral discs on the progression of ossification of the posterior longitudinal ligaments.

STUDY DESIGN: Strain distribution in the intervertebral discs was evaluated biomechanically using an engineering true strain calculation formula. OBJECTIVES: This study was performed to clarify the involvement of dynamic factors in the progression of ossification of the posterior longitudinal ligament. SUMMARY OF BACKGROUND DATA: In patients with ossification of the posterior longitudinal ligament of the cervical spine, ossification frequently progresses after laminectomy. This suggests the involvement of dynamic factors in the progression of ossification. However, these factors have not yet been clarified. METHODS: The analysis was performed on 101 patients with ossification of the posterior longitudinal ligament by employing dynamic lateral x-ray films of the cervical spine. The x-ray films were digitized and used as computer data for calculating the strain distribution. X-ray films were obtained again 5 years later, and the strain distribution and the presence or absence of progression of ossification were evaluated. RESULTS: The progression of ossification of the posterior longitudinal ligament was highly correlated with abnormal strain distribution in the intervertebral discs. Progression of ossification was frequently observed in areas having disc distortion in tension and extension on the posterior longitudinal ligament. CONCLUSIONS: In this study, the area of progression of ossification corresponded to the area showing uneven strain distribution and resultant concentration of dynamic stress. These results suggest an important role for dynamic factors in the progression of ossification of the posterior longitudinal ligament.

Adult↗
PubMed1996

Selecting a surgical method for thoracic myelopathy caused by ossification of the posterior longitudinal ligament.

STUDY DESIGN: The authors classified typical distributional patterns of ossification of the posterior longitudinal ligament of the thoracic spine in 1) central part of S-curve, 2) just above apical vertebra, and 3) combined with ossification of ligamentum flavum below apical vertebra. The results of the surgical methods selected according to the authors' classification were compared with those of previous reports. OBJECTIVES: To establish the criteria for selecting an appropriate surgical method for ossification of the posterior longitudinal ligament of the thoracic spine. SUMMARY OF BACKGROUND DATA: Poor surgical results for ossification of the posterior longitudinal ligament of "middle or lower thoracic spine" have been reported, but the unsuccessful location and curve has not been strictly defined. METHODS: The authors studied postsurgical results in 26 cases of thoracic myelopathy caused by ossification of the posterior longitudinal ligament. They also investigated radiographs of 111 cases, including 85 patients under observation, and examined the relationships between thoracic spine alignment and ossification of the posterior longitudinal ligament distribution. RESULTS: Twenty-three patients treated with methods conforming to the authors' criteria achieved satisfactory recovery in walking ability except for one patient. The results of the other three patients who underwent surgery with nonconforming methods were uneven. CONCLUSION: Posterior decompression, as well as anterior decompression, is effective in the first pattern in the cervicothoracic region. In case of the second pattern, the responsible ossification of the posterior longitudinal ligament always lies one or two levels above the apical vertebra and should be removed by anterior approach, regardless of the extent of kyphosis. Transthoracic anterior decompression surgery is considered the best method for most patients under the second and third patterns.

Adult↗
PubMed1998

An immunohistochemical study of innervation of lumbar spinal dura and longitudinal ligaments.

STUDY DESIGN: An immunocytochemical study of nerve fibers in lumbar spinal dura and longitudinal ligaments was conducted in New Zealand white rabbits. OBJECTIVES: To demonstrate the presence of nerve fibers and to establish the presence of nociceptive and sympathetic nerve fibers in lumbar dura and longitudinal ligaments. SUMMARY OF BACKGROUND DATA: The role of dura as a source of low back pain is still unclear, and the data present a somewhat conflicting picture of the nature of nociceptive innervation in this tissue. METHODS: An immunocytochemical method was used to study dura and longitudinal ligaments from New Zealand White rabbits. RESULTS: Numerous fine nerve fibers and some small bundles were demonstrated in both the dura and the longitudinal ligaments. In dorsal dura, the fibers were seen at lateral margins running toward midline. In ventral dura and longitudinal ligaments, the fibers were seen throughout the substance of these tissues. A population of substance P, calcitonin gene-related peptide, and tyrosine hydroxylase-reactive nerve fibers were observed in all the tissues. In addition, fibers exhibiting nicotinamide adenine dinucleotide phosphate diaphorase activity were also observed, indicating the presence of nitric oxide in dura. CONCLUSIONS: The results clearly demonstrate an extensive distribution of nerve fibers in dura and longitudinal ligaments. The presence of a significant number of putative nociceptive fibers supports a possible role for these structures as a source of low back pain and radicular pain.

Animals↗
PubMed1999

The ligaments and annulus fibrosus of human adult cervical intervertebral discs.

STUDY DESIGN: Descriptive, microdissection study. OBJECTIVE: To determine the morphology of the human adult cervical intervertebral disc and its ligaments. SUMMARY OF BACKGROUND DATA: Some studies indicate that the cervical disc is distinctly different from the lumbar intervertebral disc, yet most clinical and anatomic texts appear content with extrapolating data from the lumbar spine. A detailed three-dimensional description of the cervical intervertebral disc and its surrounding ligaments is currently unavailable. METHODS: Whole cervical spinal columns were freed from 12 human adult embalmed cadavers, and the posterior elements and soft tissues were removed. Using microdissection, the longitudinal ligaments and the fibrous components of 59 cervical intervertebral disc were resected systematically. The orientation, location, and attachments of each stripped bundle of collagen were recorded photographically and in sketches. RESULTS: The cervical anulus fibrosus does not consist of concentric laminae of collagen fibers as in lumbar discs. Instead, it forms a crescentic mass of collagen thick anteriorly and tapering laterally toward the uncinate processes. It is essentially deficient posterolaterally and is represented posteriorly only by a thin layer of paramedian, vertically orientated fibers. The anterior longitudinal ligament covers the front of the disc, and the posterior longitudinal ligament reinforces the deficient posterior anulus fibrosus with longitudinal and alar fibers. CONCLUSIONS: The three-dimensional architecture of the cervical anulus fibrosus is more like a crescentic anterior interosseous ligament than a ring of fibers surrounding the nucleus pulposus.

Adult↗
PubMed2001

Fibrocartilage in the transverse ligament of the human atlas.

STUDY DESIGN: Immunohistochemical investigation. OBJECTIVE: To determine whether molecules typical of articular cartilage are present in the transverse ligament and whether the ligament may be a target for an autoimmune response in rheumatoid arthritis. SUMMARY OF BACKGROUND DATA: In chronic rheumatoid arthritis there is often a marked instability of the atlantoaxial complex, and the transverse ligament can show degenerative changes that compromise its mechanical function. In some rheumatoid patients there can be an autoimmune response to cartilage link protein, aggrecan, and Type II collagen. METHODS: Transverse ligaments were removed from 13 cadavers and fixed in 90% methanol. Cryosections were immunolabeled with antibodies against proteoglycans (aggrecan, link protein, and versican), glycosaminoglycans (chondroitin-4-sulfate, chondroitin-6-sulfate, dermatan sulfate, and keratan sulfate), and collagens (Types I, II, III, and VI). RESULTS: Labeling for aggrecan and link protein was characteristic of the fibrocartilages, but versican was only detected in the fibrous regions. Equally, Types I, III, and VI collagens and keratan, dermatan, and chondroitin-4-sulfates were found throughout the ligament, but labeling for Type II collagen and chondroitin-6-sulfate was restricted to the fibrocartilages. CONCLUSION: The presence of molecules typical of articular cartilage (aggrecan, link protein, and Type II collagen) in the transverse ligament explains why it can be a target for destruction in rheumatoid arthritis and also suggests that it is subject to constant compression against the dens rather than only at the extremes of movement.

Aged↗
PubMed2002

Association of bone metabolism regulatory factor gene polymorphisms with susceptibility to ossification of the posterior longitudinal ligament of the spine and its severity.

STUDY DESIGN: A case-control association study and a stratified study investigating the genetic etiology for ossification of the posterior longitudinal ligament of the spine. OBJECTIVE: To determine the association of restriction fragment length polymorphisms of estrogen receptor, vitamin D receptor, parathyroid hormone, and interleukin-1alpha and -1beta with susceptibility to ossification of the posterior longitudinal ligament of the spine and its severity. SUMMARY OF BACKGROUND DATA: Contribution of genetic backgrounds to the etiology for ossification of the posterior longitudinal ligament of the spine has been suggested by epidemiologic studies. METHODS: Genomic deoxyribonucleic acid samples obtained from 120 patients (77 men and 43 women) with ossification of the posterior longitudinal ligament of the spine and 306 control subjects without the disorder (166 men and 140 women) were amplified by polymerase chain reaction, and polymorphism genotypes were determined by restriction endonuclease digestion. The distribution of genotypes was compared between patients with the disorder and control subjects. In addition, the severity of ossification was determined by the number of ossified vertebrae in patients with the disorder, and associations of the severity with age, gender, and genotypes were examined. RESULTS: Estrogen receptor (P = 0.007) and interleukin-1beta (P = 0.001) polymorphisms exhibited different distributions between patients with ossification of the posterior longitudinal ligament of the spine and control subjects in women, but not in men. In patients with the disorder, the severity of ossification was negatively correlated with age in women (P = 0.013), but not in men. Estrogen receptor polymorphism was associated with the severity only in women (P = 0.001). CONCLUSIONS: The contribution of genetic backgrounds is likely to be stronger in women than in men with ossification of the posterior longitudinal ligament of the spine. Estrogen receptor polymorphism was associated with both initiation and promotion of the disorder, but interleukin-1beta polymorphism was associated only with its initiation in women.

Adult↗
PubMed1998

Localization and characterization of porcine patellar tendon xenograft antigens in a rabbit model of medial collateral ligament replacement.

BACKGROUND: Ligament injuries of the knee are common and, if severe, can predispose to joint pain, instability, reinjury, and, ultimately, osteoarthritis. Xenograft replacement of ligaments could have potential; however, a limited understanding of the immunology of ligament xenograft rejection has inhibited their use. The purpose of this study was to characterize the antigenic elements of a fresh porcine tendon xenograft in a rabbit model and to provide a better understanding of what would need to be done to either block or extract these antigenic elements. METHODS: Three experimental situations were evaluated in a pig to rabbit ligament transplantation model: subcutaneous implantation of fresh porcine patellar tendon (PPT), implantation of fresh PPT into a medial collateral ligament midsubstance gap, and replacement of the entire medial collateral ligament complex with either fresh or guanidinium hydrochloride-extracted PPT. Preimmune and immune sera were collected from rabbits and used to localize antigenic targets in PPT, meniscus, and cartilage with indirect immunofluorescence techniques. The reactivities of the same rabbit sera towards tissue extracts of PPT, meniscus, and cartilage by Western immunoblot analyses were used to characterize the antigenic components. RESULTS: Indirect immunofluorescence with preimmune rabbit sera on PPT showed staining of tendon fibroblasts. Immune sera from rabbits transplanted with xenografts stained regions of the extracellular matrix of PPT. Fresh PPT induced antibodies that consistently recognized six extracellular matrix components with molecular masses of >200 kDa, 180 kDa, 135 kDa, 108 kDa, 63 kDa, and 59 kDa. CONCLUSIONS: Our results suggest that naturally occurring rabbit anti-pig antibodies of the IgG isotype recognize immunogenic components on tendon fibroblasts, whereas induced rabbit anti-pig antibodies recognize a specific subset of six extracellular matrix components of PPT. PPT xenografts appeared to induce a similar humoral immune response irrespective of graft location. Finally, our results indicate that selective extraction of PPT xenograft components before implantation altered the induced rabbit anti-pig antibody response; however, such extraction did not change the ultimate fate of the transplant tissue.

Animals↗
PubMed2004

Dorsal wrist ligament insertions stabilize the scapholunate interval: cadaver study.

This study examined sequential arthroscopic sectioning of volar, interosseous, and dorsal ligaments about the scapholunate complex in cadaver wrists. We attempted to clarify the contributions of the dorsal ligamentous complex to scapholunate instability and carpal collapse. We found that after sequential sectioning of volar ligaments and the scapholunate interosseous ligament, no scapholunate diastasis or excessive scaphoid flexion occurred. After dividing the dorsal intercarpal ligament, scapholunate instability occurred without carpal collapse. With sectioning of the dorsal radiocarpal ligament from the lunate, a dorsal intercalated scapholunate instability deformity ensued. This information may be of value in comprehending the pathogenesis of scapholunate instability and carpal collapse and in devising the rationales for conservative measures and surgical intervention.

Arthroscopy↗
PubMed2004

Effect of tibial slope or posterior cruciate ligament release on knee kinematics.

An experimental study using fresh human cadaver knees was designed to evaluate the effect of partial posterior cruciate ligament release or posterior tibial slope on knee kinematics after total knee arthroplasty. Varus and valgus laxity, rotational laxity, anteroposterior laxity, femoral rollback, and maximum flexion angle were evaluated in a normal knee, an ideal total knee arthroplasty, and a total knee arthroplasty in which the ligaments were made to be too tight in flexion. The total knee arthroplasty specimens then were subjected to either partial posterior cruciate ligament release or increased posterior tibial slope, and the tests were repeated. Posterior tibial slope increased varus and valgus laxity, anteroposterior laxity, and rotational laxity in the knee that had flexion tightness. Posterior cruciate ligament release corrected only anteroposterior tightness, and had no effect on the abnormal collateral ligament tightness. Increased posterior tibial slope significantly improved varus and valgus laxity and rotational laxity in the knee that was tight in flexion more than with release of the posterior cruciate ligament. Therefore increasing posterior tibial slope is preferable for a knee that is tight in flexion during total knee arthroplasty.

Arthroplasty, Replacement, Knee↗