4. The articular surfaces are the
medial and lateral femoral
condyles (the intercondylar
notch in between)
The medial condyle has a
longer articular surface
The superior aspect of the
medial and lateral tibial
condyles
The posterior aspect of the
patella
5. Average is 17 mm
Narrow notch more likely to
tear ACL
6.
7. Sesamoid bone
Thickest articular cartilage
in body
Smaller medial facet
Q-angle
Controlled by Vastus
Medialis Obliquus (VMO)
and Vastus Lateralis
Obliquus (VLO)
8. The patella is controlled by the oblique
portions of the vastus medialis and vastus
lateralis.
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 on extension
of the knee. This results in
retropatellar pain
9.
10. Lower most fibres of vastus
medialis
Partly arise adductor magnus
Straightens the pull on the quads
tendon and patella
Controls patella tracking during
flexion extension of the knee
Fibres atrophy quickly after knee
injury
10-15 ml of effusion inhibit VMO
VMO rehabilitation strength and
timing of contraction
13. Quadriceps tendon
The patella
The patellar ligament
Retinacular fibres all form the
anterior part of the capsule
The patellar ligament is the insertion
of the quadriceps tendon
14. Antero-inferiorly is attached to the
tuberosity of the tibia
On either side the retinacular fibres
pass upwards from the tuberosity in
a V-shaped manner to be attached
just below the articular margin
The deep infrapatellar bursa and
infrapatellar pad of fat lie posterior to
it, separating it from the tibia
15. Laterally, the attachment is just beyond
the articular margin
Laterally, it is attached above the groove
for the popliteus, below the lateral
epicondyle
There is a gap in the capsule to allow
the popliteus to emerge
16. Posterior
Superiorly, it is attached just
beyond the articular margin
and to the lower border of
the popliteal surface of the
femur, above the
intercondylar notch
17. Postero-inferiorly, the
capsule is attached to
the medial condyle of
the tibia
By a line running
above the groove for
the semimembranosus
tendon
Below the attachment
of the posterior
cruciate ligament
18. Medially, the capsule is
attached to the femur
just beyond the articular
margin of the condyle
Below the medial
epicondyle
20. Medial ligament
Pes anserinus consists
of:
Sartorius
Gracilis
Semitendinosus
Tibial inter-tendinous
bursa between them
21. Is attached superiorly to the
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
It has a superficial and deep
portion
The deep portion, which is short,
fuses with the capsule
Attached to the medial meniscus
A bursa usually separates the
two parts
22. The tendons of
sartorius, gracilis and
semitendinosus cross its
tibial attachment where
another bursa is situated
The anterior part
tightens during the first
70–105°of flexion
23. 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
25. Semimembranosus into
the groove on posterior
aspect of medial tibial
condyle and its extensions
Upwards and lateral is
oblique popliteal ligament
Downwards and lateral
forms fascia covering
popliteus
Downwards and medially
fuses with medial ligament
26. Oblique popliteal ligament
passes upwards and laterally
Fuses with the fabella if
present
Capsule above lateral femoral
condyle
Pierced by middle genicular
vessels and nerve
Posterior division of obturator
nerve
Popliteal artery lies on it
Oblique Popliteal Ligament
27. Strengthens the posterior portion
of the capsule and prevents
extreme lateral rotation
It is an expansion from the
semimembranosus tendon close
to its insertion to the tibia
Branch from the posterior division
of the obturator nerve, pierces the
ligament, supplies cruciates and
articular twig to knee (referred
pain from pelvic peritoneum to
knee)
Oblique Popliteal Ligament
30. Posterior horn of
lateral meniscus
Arcuate complex
Popliteus
Lateral head of
gastrocnemius
31. Deep in interval between
iliotibial band and biceps
Lateral epicondyle of
femur
Midpoint superior surface
of fibula and the styloid
process of the fibula
It is a cord-like structure
that is separated from the
capsule by the tendon of
the popliteus
Surrounded by biceps
Fabbriciani & Oransky, 1992
Lateral Ligament
32. Deep to lateral collateral
ligament
Popliteus
Inferolateral genicular
vessels and nerve
33. Taut in extension
20°flexion, lateral ligament
complex more lax than
medial
Primary lateral restraint to
varus loading
Arcuate ligament is the edge
of capsule that arches above
the popliteus
34. Passes from the tip of the
styloid process
Just posterior to the lateral
ligament
Blends origin of the lateral
head of gastrocnemius and
oblique popliteal ligament
Edge of capsule arches over
popliteus and may give
partial origin to popliteus
35. Fabella lies at point
on the poster lateral
side of knee
Where
multidirectional
collagenous tensile
stress meet
8% - 10% osseous
90% - 92%
cartilagenous
Fabbricani & Oransky, 1992
36. 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
37. Origin inferior, popliteal
surface of tibia, above the
soleal line, fascia of
semimembranosus
Deep to arcuate popliteal
ligament
Enters capsule
Crosses lateral surface of
lateral meniscus
Attached by popliteal-
meniscal fibres which bound
hiatus
38. Enters hiatus
Crosses femoral
condyle
Deep to lateral
collateral ligament
Inserts into anterior
part of groove
Superior popliteal
recess
communicates joint
39. Femoral condyles
rotate medially around
taut ACL during the
locking mechanism of
the knee
Popliteus laterally
rotates the femur to
unlock the knee so
flexion can occur
40. The iliotibial tract is a thickening of the
deep fascia of the thigh, fascia lata
The tract is attached to Gerdy’s tubercle
on the anterolateral aspect of the lateral
tibial condyle
The superficial three quarters of the
gluteus maximus end in a thick tendinous
lamina which is inserted into the iliotibial
tract
The tensor fascia lata is also inserted into
the tract
Gives origin to the oblique fibres of the
vastus lateralis that help to stabilise the
patella
41. In full knee extension the tract
lies anteriorly to the line of
flexion of the knee,
As it is free of bony
attachments between the
lateral femoral epicondyle and
Gerdy’s tubercle
It is free to move posteriorly to
this axis on flexion of the knee
Standish & Wood, 1996.
As the tract crosses the lateral
epicondyle of the femur a
bursitis may develop as the
result of a ‘long-leg syndrome’
42. The iliotibial band acts as an
extensor of the knee when the
knee is flexed from 0°to 30°and
as a flexor when the knee is
flexed more than 40°, due to the
change in the transverse axis
which occurs at
30–40°flexion.
The pelvic tilt is a mechanism for
tightening the iliotibial band. The
pull of the band stabilises the
knee in extension, as well as
helping to resist extension and
adduction of the hip of the weight-
bearing leg
43. Flexion and extension
take place between the
femoral condyles and
the upper surface of the
menisci
Rotation occurs between
lower surface of the
menisci and upper
surface of the tibia
44. 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
45. Femoral condyles rotate
medially around taut ACL
during the locking
mechanism of the knee
Popliteus laterally rotates
the femur to unlock the
knee
So flexion can occur
Then the hamstrings flex
the knee
46.
47.
48. Anatomically named by
their tibial attachments
Clinically femoral are
called origin
Covered by synovial
membrane on anterior
and on both sides which
is reflected from capsule,
I.e. oblique popliteal
ligament
Bursa between them on
lateral aspect
anterior
lateral
49. Synovial membrane
covers the anterior and
sides of the cruciates
Not covered on
posterior aspect
Anterior and Posterior
Cruciates Ligament
50. Anterior cruciate is
attached to anterior aspect
of the superior surface of
the tibia behind
Anterior horn of medial
meniscus in front of the
anterior horn of the lateral
meniscus
Passes upwards and
laterally to the posterior
aspect of medial surface
of lateral femoral condyle
Anterior Cruciate
54. Tibial attachment is in
antero-posterior axis of
tibia
Femoral attachment is in
longitudinal axis of femur
Forms 40°with its long
axis
90°twist of fibres from
extension to flexion
Anterior Cruciate Ligament
55. Anteromedial fibres
have the most
proximal femoral
attachment
Contribute to
anteromedial stability
Intermediate to
straight and
anteromedial
Posterolateral aids in
anteromedial stability
Anterior Cruciate Ligament
56. ACL are vertical in
extension
90°flexion are
horizontal
PCL are more
vertical in 90°flexion
Anterior Cruciate Ligament
57. At 0°of flexion the fibres of
the ACL are more vertical
At 90°flexion they are in the
horizontal plane
Fibres of the PCL are more
vertical with flexion and
increasing flexion,
> 90°becomes pivot
PCL is least affective at
30°flexionHunziker et al 1992, Covey 2001
Cruciate
58.
59. PCL
Provides 94% of
restraint to posterior
displacement
ACL
Provides 86% of
restraint to anterior
displacement
Anterior and Posterior Cruciate
60. Middle genicular
artery
Inferior medial
genicular
Inferior lateral
genicular arteries via
infrapatellar fat pad
Only one main
artery
Middle genicular
enters upper third
Anterior Cruciate Ligament
Blood Supply
61. Strongest ligament
Shorter
More vertical
Less oblique
Twice as strong as
ACL
Posterior
Posterior Cruciate
62. PCL is the strongest
ligament of the knee
It is shorter
More vertical
Less oblique
Twice as strong as
ACL
Closely applied to the
centre of rotation of
knee
It is the principal
stabiliser
Hunziker et al.,1992
Posterior Cruciate
63. The tibial attachment of
the PCL was on the
sloping posterior portion
of the tibial
intercondylar area
Anterior to tibial
articular margin
Blends with periosteum
and capsule
Extended 11.5-17.3 mm
distal to the tibial
plateau
Javadpour & O’Brien, 1992
65. Anatomically the fibres pass
anteriorly and medially and
proximally
It is attached on the antero-
inferior part of the lateral
surface of the medial
femoral condyle
The area for the PCL is
larger than the ACL
It expands, more on the
apex of the intercondylar
notch than on the inner wall
Hunziker et al.1992
.
Posterior Cruciate
66. Three functional bands
Names vary
Anterior or anterolateral is
larger
Central
Taut in flexion
Posterior or posteromedial
taut in extension
Posterior oblique bundle
Hunziker et al 1992
Posterior Cruciate Ligament
67. Insertions of the PCL
Passes through four
zones
Ligament
Fibrocartilage
Tidemark of mineralised
fibrocartilage
Bone in less than 1 mm
Cooper & Misol, 1970; Fabbriciani & Oransky, 1992
Attachment of PCL
68. Posterior oblique bundle
Most posterior fibres
Attached to
posterosuperior part of
femur
Posterior medial part on
intercondylar area of
tibia
Longest fibres
Tense in full extension
Fredrick & O’Brien, 1992; Hunziker et al.,1992
Posterior Cruciate Ligament
69. Proximal fibres on femur
Posterior fibres on the tibia
are longest
Undergo least change
Posterior Cruciate
70. The PCL is located
near the longitudinal
axis of the knee
Medial to the centre of
the knee
Vertical in frontal
plane
30°to 35°in sagittal
More horizontal in
sagittal with increased
flexion
Posterior Cruciate
71. PCL provides 94% of
restraint to posterior
displacement of the tibia
Prevents external rotation of
tibia more at 90°than at 30°
ACL 86% of restraint to
anterior displacement
Posterior Cruciate
73. Posterior cruciate is
supplied by four
branches
Distributed fairly
evenly over its course
Subcortical vascular
network at bony
attachments
Don’t contribute much
to ligaments
Sick & Koritke, 1960
Blood Supply of Cruciates
74. Main is middle genicular
artery enters upper third
of PCL
Synovium surrounding
PCL also supplies the PCL
Contributions inferior
medial, inferior lateral
genicular arteries via
infrapatellar fat pad
Periligamentous and intra-ligamentous
plexus
Very little from bony attachment
Arnoczky 1987
Blood Supply of PCL
75. Branches of tibial
and obturator
nerves
Mechanoreceptors
Proprioceptive
action
Posterior Cruciate Ligament
Nerve Supply
76. Branches of tibial
nerve
Middle genicular nerve
Obturator nerve (post)
Branches of the tibial
nerve enter via the
femoral attachment of
each ligament
Nerve fibres are found
with the vessels in the
intravascular spaces
Nerve Supply of Cruciates
77. Three types
Found near the femoral
attachment
Around periphery
Superficially, but well below the
synovial lining.
Where maximum bending
occurs
Ruffini endings
And ones resemble golgi
tendon organs
Paccinian
Proprioceptive function
78. Mechanoreceptors
resembling golgi tendons
Running parallel to the
long axis of the ligament
Found near the femoral
attachment
Around the periphery,
where maximum bending
occurs
Posterior division of
obturator nerve
79. There is a gradual change in
stiffness between the flexible
ligamentous tissue and bone
There is a transitional zone of
fibrocartilage between
collagen and bone
This helps to prevent the
concentration of stress at the
attachment site
Beynnon, 2000; Hunziker et al.,1992
Posterior Cruciate Ligament
Bony Attachment
80. 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
anterior
81. 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
82. Medial is attached to the
deep portion of medial
collateral ligament
Lateral is separated from
lateral ligament by the
inferolateral genicular
vessels and nerve
The popliteus, which is
attached to lateral
meniscus
Posterior horn gives
origin to meniscofemoral
ligament
83. Coronary ligaments
are the portion of the
capsule attached to
the periphery of
meniscus, which
connects it to the tibia
Synovial membrane,
stops at the upper
border of the
meniscus
Lines the deep aspect
of the coronary
ligament
84. Blood supply at the
periphery only
Flexion and extension
takes place at the
upper surface of the
menisci
Rotation occurs
between the lower
surface of the menisci
and the tibia anterior
85. Shock absorption
Redistributes forces
Spread synovial fluid
Minimal effect on stability
On rotation menisci move with
femur
Lateral moves 20 - 24 mm
Medial less mobile 10 -15 mm
Lateral meniscus bears more
load
Function of Menisci
86. Anterior and posterior arise
from posterior horn of
lateral meniscus
Anterior attached to femur
anterior to PCL
Posterior attached
posterior to PCL
More variations in posterior
87. The Anterior meniscofemoral
(Humphrey) is attached to
lateral aspect of the medial
femoral condyle in front of the
PCL
The posterior (Wrisberg) is
attached posterior to the PCL
The posterior meniscofemoral
ligament is usually present
Vary in size
88.
89. Increase with age
Compact lobules
With fibro-elastic
interlobular septa
Septa well vascularised
Provide firmness,
deformability and elastic
recoil
Williams & Warick,1980
90. Superiorly
Fills the space between the
inferior pole of the patella
The ligamentum patella and
deep infrapatella bursa
Attached to intercondylar
notch via ligamentum
mucosum
Williams & Warick,1980
91. Posteriorly
Covered by synovial
membrane
Forms alar folds
Femoral condyles
Intercondylar notch
by ligamentum
mucosum
Attached to anterior
horns of menisci
Proximal tibia
Williams & Warick,1980
92. Blood supply inferior
genicular arteries
Also supply the lower
part of the ACL from
network of synovial
membrane of fat pad
Centre of fat pad
limited blood supply
Lateral arthroscopic
approach to avoid
injury
Kohn et al., 1995; Eriksson et al., 1980
93. Can only expand anteriorly
Inflammation of IFP
Bulges on either side of
patellar tendon
Synovial membrane is
compressed by femoral
condyles
Pain and inflammation
95. Hyperextension injury
Genu recurvatum and
tilted inferior pole of patella
Tenderness distal to
patella
Beyond margins of the
patella
Brukner & Khan, 2000; Garret et al., 2000
96. Anterior extra
capsular disorders
Patellar fracture
Patellar tendon
rupture
Deep infrapatellar
bursitis
Patellar tendonosis
98. 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
99.
100. The synovial membrane
is very extensive
It lines the inner aspect
of the capsule and the
non-articular structures
inside the capsule,
except posteriorly where
it is carried forwards to
cover the anterior and
sides of the cruciate
ligaments
101. It covers the infrapatellar pad of
fat, forming the alar folds
The ligamentum mucosum is
attached to the intercondylar
notch at the apex of the alar fold
The alar folds increase the
surface area of the synovial
membrane via the infrapatellar
pad of fat,
Which fill the changing spaces
during movement of the joint and
help to redistribute the synovial
fluid
102. The synovial membrane is
continuous with:
The suprapatellar bursa
which extends a hand’s
breadth above the patella.
This bursa always appears
distended when there is a
haemarthrosis or traumatic
synovitis in the knee joint
Many other bursae, e.g.
around the popliteus and
under the medial head of
the gastrocnemius
103. A suprapatellar plica may
separate the suprapatellar
bursa from the synovial
membrane of the knee joint
Plicae folds may also be
found on either side of the
patella
110. Valgus / External rotation
Posterior horn of medial
meniscus trapped by
posterior condyles
111.
112. • Medial meniscus has higher incidence but
less morbidity
• Traumatic tears
• Twisting on a planted, flexed knee
• Atraumatic tears
• Degenerative wear and tear
Hinweis der Redaktion
Anterior on femur
Posterior Cutaneous nerve of thigh <Posterior Cutaneous of calf