Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Ligament
condyles
• The medial condyle has
a longer articular surface
• The superior aspect of
the medial and lateral
tibial condyles
• The posterior aspect of
the patella
Articular Surfaces
• Two condyles are separated behind
by the intercondylar notch
• Joined in front by the trochlear
surface for the patella
• Femoral condyles are eccentrically
curved
• Medial is of more constant width. It
is narrow, longer and more curved
• Lateral condyle is broad and straight and diverges slightly medial
distally and posteriorly, wider in front than at the back
Last, 1984
Femoral Condyles
• The radius of the condyles' curvature is
in the saggital plane,
• Becomes smaller toward the back
• This diminishing radius produces a
series of involute midpoints (i.e. located
on a spiral)
• The resulting series of transverse axes,
permit the sliding and rolling motion in the flexing knee
• While ensuring the collateral ligaments are sufficiently lax
to permit the rotation associated with the curvature of the
medial condyle about a vertical axis
Platzer, 2004
Intercondylar Notch
• Intercondylar notch is a continuation of the
trochlea
• Varies in shape and size
• Female knee, intercondylar
notch and ACL tend to be smaller
• The mean notch width was
13.9 +/- 2.2 mm for women and 15.9 +/- 2.5
mm for men,
average is 17 mm
• Narrow notch more likely to tear the anterior
cruciate ligament
Domzalski et al., 2010; Shelbourne et al.,1998; Griffin et al., 2006
Tibial Superior Articular Surface
• The medial facet, oval in shape, medial
is slightly concave from side to
side, and from before backward
• The lateral, nearly circular, is
concave from side to side
• But slightly convex from before
backward, especially at its
posterior part
• Where it is prolonged on to the
posterior surface for a short
distance
Tibial Superior Articular Surface
• The central portions of these
facets articulate with the
condyles of the femur
• Their peripheral portions
support the menisci of the
knee-joint
• The intercondylar eminence is
between the articular facets
• Nearer the posterior than the
anterior aspect of the bone
Tibial Superior Articular Surface
PCL
• In front and behind the
intercondylar eminence are
rough depressions for the
attachment of the anterior
and posterior cruciate
ligaments and the menisci
• The shape of the cruciate
attachments vary lateral
meniscus
ACL
anterior
Patella
• Sesamoid bone
• Thickest articular cartilage
in body
• Smaller medial facet
• Q angle
• Controlled by vastus medialis obliquus
(VMO) and vastus lateralis obliquus (VLO)
Patella
• The vastus medialis wastes within
24 hours after an effusion of the
knee
• If the oblique fibers of the vastus
medialis are wasted
• The patella tends to sublux laterally
when the knee is extended
• This results in retro patellar pain
Capsular Ligaments
• Quadriceps
• Retinacular fibres
• Patellar tendon
• Coronary ligaments
• Medial and lateral ligaments
• Posterior oblique ligament
Infrapatellar Fat Pad (IFP)
• Posteriorly
• Covered by synovial membrane
• Forms alar folds
• Blood supply of fat is by the inferior genicular
arteries
• Also supply the lower part of the ACL from
network of synovial membrane of fat pad
• Centre of fat pad has a limited blood supply
• Lateral arthroscopic approach to avoid injury
Williams & Warick, 1980; Eriksson et al., 1980; Kohn et al., 1995
Infrapatellar Fat Pad (IFP)
• ACL repair with patellar tendon may result in
fibrosis of fat pad and pain
• Delays rehabilitation
• Inflammation of IFP may be process leading
to fibrosis
Murakami et al., 1995
Anterior and Posterior Cruciates
oblique popliteal
• Anatomically named by their ligaments
tibial attachments
• Clinically, femoral attachments
are called the origin
lateral
• Cruciates are intracapsular
but extrasynovial
• Cross in the sagittal plane
ACL
• Covered by synovial membrane on
anterior and on both sides which is anterior
reflected from capsule, i.e. oblique
popliteal ligament
• Bursa between them on lateral aspect
Anterior Cruciate Ligaments
ACL
ACL
anterior
Cruciate Ligaments
• ACL average length 31-38 mm
• ± 10 mm width and ± 5 mm thick
Odenstein, 1985; Girgis, 1975
• PCL average length 28-38 mm
• PCL is 13 mm wide
• Cruciates have a constant length ratio
• ACL : PCl of 5:3
Girgis et al., 1975
Anterior Cruciate Ligaments
• Three dimensional fan shaped
• Multiple non-parallel interlacing collagenous
fascicles
• Made up of multiple collagen fascicles;
surrounded by an
endotendineum
• Microspically: interlacing fibrils
(150 to 250 nm in diameter)
• Grouped into fibers (1 to 20 µm in diameter)
synovial membrane envelope
Jackson et al., 1993
Anterior Cruciate Ligaments
• Anterior cruciate is attached to
anterior aspect of the superior
surface of the tibia
• Behind the anterior horn of
medial meniscus and in front of
the anterior horn of the lateral
meniscus
lateral
• Passes upwards and laterally to
the posterior aspect of medial
surface of lateral femoral ACL
condyle
Tibial Attachment
• Tibial attachment is in a fossa in front
of and lateral to anterior spine Medial
• Attachment is a wide area from 11
mm in width to 17 mm in AP direction
• Some anterior fibers go forward to
level of transverse meniscal
ligament; into the interspinous area
of the tibia; forming a foot-like
attachment
PCL Posterior ACL
• Larger tibial than femoral attachment meniscofemoral
O’Brien, 1992
Anterior Cruciate Ligaments
• The anterior cruciates limit extension
and prevent hyperextension
• The anterior cruciate ligament is most
at risk during forced external rotation
of the femur on a fixed tibia with the
knee in full extension
Stanish et al., 1996
• .
Cruciates Microscopic
• Collagen fibrils 150-200 µm in diameter
• Fibres 1-20 µm in diameter
• A subfascicular unit from100-250 µm
• 3 to 20 subfascicular units form
collagen fasciculus, 250 µm to several
millimetres
Hunziker et al.,1992
Blood Supply of
Anterior Cruciate Ligaments
• Middle genicular enters upper third
and is the major blood supply via
synovium
• Inferior medial genicular and Inferior
lateral genicular arteries supply via
infrapatellar fat pad
• Bony attachments do not provide a
significant source of blood to distal or
proximal ligaments
Arnoczky 1987
Blood Supply of Cruciates
Blood Supply of
Posteriro Cruciate Ligaments (PCL)
• PCL is supplied by four branches
• Distributed fairly evenly over its course
• Main is middle genicular artery enters
upper third of PCL
• Synovium surrounding PCL also
supplies PCL
• Contributions inferior medial, inferior lateral genicular arteries
via infrapatellar fat pad
• Periligamentous and intra-ligamentous plexus
• Sub cortical vascular network at bony attachments
• Very little from bony attachment
Sick & Koritke, 1960; Arnoczky, 1987
Nerve Supply of Cruciates
• Branches of tibial nerve
• Middle genicular nerve
• Obturator nerve (post division)
• Branches of the tibial nerve enter
via the femoral attachment of each
ligament
• Nerve fibres are found with the
vessels in the intravascular spaces
• Mechanoreceptors
• Proprioceptive action
Nerve Supply of IFP
• Posterior articular branch of
tibial nerve
• Fat pad
• Supplies cruciates
• Synovial lining of cruciates
• Mechanoreceptors and pain
sensitive
Kennedy et al., Freeman & Wyke, 1967
Mechanoreceptors
• Three types, found near the femoral
attachment
• Around periphery
• Superficially, but well below the
synovial lining
• Where maximum bending occurs
• Ruffini endings, paccinian corpuscles
• Ones resemble golgi tendon organs, running parallel to the
long axis of the ligament
• Proprioceptive function
• Posterior division of obturator nerve
Sensory Reflex
• Sensory information from the ACL
assists in providing dynamic stability
• Strain of ACL results in reflex
contraction of the hamstrings
• Protects ACL from excessive loading
by pulling the tibia posteriorly
• Rapid loading ACL may rupture
before it can react
Extension Screw Home
• Contraction of the quadriceps results in
extension
• The anterior cruciate becomes taut
• And medial rotation of the femur occurs
around the taut anterior cruciate to
accommodate the longer surface of the
medial condyle
• During extension the ACL lies in a smaller anterolateral notch
in the main intercondylar notch
• It can be kinked or torn here during hyperextension,
particularly if there is violent hyperextension and internal
rotation
Extension
• The anterior horns of the
menisci block further movement
of the femoral condyles
• The posterior portion of the
capsule and the collateral
ligaments are also tight: this is
the close-packed position of the
joint
Flexion
• Popliteus laterally rotates the femur
to unlock the knee
• So flexion can occur
• Then the hamstrings flex the knee
• The axis around which the motion
takes place is not a fixed one, but
shifts forward during extension and
backward during flexion
popliteus
Screw-Home in Extension
• The effect of the screw-home
is to transform the leg into a
rigid unit, sufficiently stable for
the quadriceps to relax
• Little muscular effort is then
needed to maintain the
standing posture
• The screw-home action is due
to the inability of the central
ligaments to increase in length
Screw-Home in Extension
• The screw-home does not
occur in the absence of the
controlling ligaments
• If the anterior cruciate and
postero-lateral complex are
missing, the lateral condyle is
not drawn forwards, resulting
in a positive pivot shift test
• Which is the abnormal
displacement of the lateral
tibial condyle on the femur
Anatomy of the Menisci
anterior
• Menisci are made of fibro
cartilage
• Wedge shaped on cross section
• Medial is comma shaped with the
wide portion posteriorly
• Lateral is smaller, two horns
closer together round
• They are intracapsular and intra
synovial
Anatomy of the Menisci
• Anterior to posterior
• Medial, anterior horn is attached
to the intercondylar area in front
of the ACL and the anterior horn
of the lateral meniscus
• Posterior horn of lateral,
posterior horn of medial and
PCL
• Medial is more fixed
• Lateral more mobile
anterior
Anatomy of the Menisci
• Medial is attached to the deep
portion of medial collateral
ligament
• Lateral is separated from lateral
ligament by the inferolateral
genicular vessels and nerve and
the popliteus
• The popliteus, is also attached to
the lateral meniscus
• Posterior horn gives origin to
meniscofemoral ligaments
Menisco-femoral Ligaments
Coronary Ligament
• Connects the periphery of the
menisci to the tibia
• They are the portion of the capsule
that is stressed in rotary movements
of the knee
Medial Collateral Ligament (MCL)
or Tibial Collateral
• Is attached superiorly to the
Ligament
medial epicondyle of the femur.
• It blends with the capsule
• Attached to the upper third of the
tibia, as far down as the tibial
tuberosity
Medial Collateral Ligament (MCL)
•
or Tibial Collateral
It has a superficial and deep
Ligament
portion
• The deep portion, which is
short, fuses with the capsule
and is attached to the medial
meniscus
• A bursa usually separates the
two parts
• The anterior part tightens during
the first 70–105°of flexion
Medial Collateral Ligament (MCL)
• Medial ligament, tightens in
extension
• And at the extremes of medial and
lateral rotation
• A valgus stress will put a strain on
the ligament
• If gapping occurs when the knee is
extended, this is due to a tear of
posterior medial part of capsule
• If gapping only occurs at 15º flexion,
this is due to tear of medial ligament