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Anatomy of Anterior CruciateAnatomy of Anterior Cruciate
LigamentLigament
By- Dr. Armaan SinghBy- Dr. Armaan Singh
Anatomy of Knee Joint
• The knee joint is the largest joint in the
body
• One of the most frequently injured
• Synovial condylar joint
• Knee has six degrees of freedom, three
translations and three rotations
• Flexion and extension occur between
femur and menisci
• Rolling occurs above the meniscus,
• Rotation between menisci and tibia
• Gliding below the meniscus
Knee Joint
• The mechanism of the injury is an
important factor in determining
which structure is damaged
• Injury to the anterior cruciate
ligament occurs in both contact
and non contact sports
• Females are more at risk
particularly gymnastics, skiing,
soccer volleyball and basketball
• A rapid effusion into a joint after
an injury is a haemarthrosis and,
in 75% of cases, is due to rupture
of the anterior cruciate ligament
Close-Packed
• Stable position
• Surfaces fit together
• Ligaments taut
• Spiral twist
• Screw home articular surface
Least-Packed
• Joint more likely to be injured least-
packed
• Capsule slackest
• Joint held in this
• Position when injured
• Knee in 20°flexion
Articular Surfaces
• The femoral articular
surfaces are the medial
and lateral femoral
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
ACL
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
distally and posteriorly, wider in front than at the back
Last, 1984
medial
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,
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
medial
• 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
Tibial Superior Articular Surface
• 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
anterior
ACL
lateral
meniscus
PCL
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
• Anatomically named by their
tibial attachments
• Clinically, femoral attachments
are called the origin
• Cruciates are intracapsular
but extrasynovial
• Cross in the sagittal plane
• 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
oblique popliteal
ligaments
ACL
Anterior Cruciate Ligaments
anterior
ACL
ACL
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
• Passes upwards and laterally to
the posterior aspect of medial
surface of lateral femoral
condyle
ACL
lateral
Tibial Attachment
• Tibial attachment is in a fossa in front
of and lateral to anterior spine
• 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
• Larger tibial than femoral attachment
• Shape of the attachment to tibia
varies
Amis,1991
ACL
Medial
PCL Posterior
meniscofemoral
Femoral Attachment
• ACL attached to a fossa on the
posteromedial corner of medial aspect of
lateral femoral condyle in the intercondylar
notch
• Femoral attachment of ACL is well
posterior to longitudinal axis of the femoral
shaft.
• Femoral attachment is in the form of a
segmented circle
• Anterior border is straight, posterior border
convex
Arnoczky et al 1983
Femoral Attachment
• Attachment is actually an
interdigitation of collagen fibers
and rigid bone, through a
transitional zone of
fibrocartilage and mineralized
fibrocartilage
• Attachment lies on a line which
forms a 40°angle with the long
axis of the femur
Muller, 1982; Frazer, 1975
ACL Bundles
• The ACL consists of a smaller
anteromedial and a larger
posterolateral bundle, which twists
on itself from full flexion to
extension
• The posterolateral bundle is larger
and longest in extension and
resists hyperextension
• The taut ACL is the axis for medial
rotation of the femur, during the
locking mechanism of the knee in
extension
Hunziker et al.,1992
ACL
Anteromedial Bundle of ACL
• Anteromedial bundle attached to
the medial aspect of the
intercondylar eminence of the
tibia
• Anteromedial fibres have the
most proximal femoral
attachment
• Anteromedial bundle is longest
and tight in flexion
• Femoral insertion of the
anteromedial bundle is the
centre of rotation of ACL
Arnoczky et al 1993
antero medial
bundle
Anteromedial Bundle
• Anteromedial bundle has an isometric
behaviour
• Tightens in flexion, while the postero
lateral bundle relaxes in flexion
• Is more prone to injury with the knee in
flexion
• Anteromedial band is primary check
against anterior translation of tibia on femur
• When anterior drawer test is performed in usual manner
with knee flexed
• Contributes to anteromedial stability
O’Brien, 1992
Posterolateral Bundle
• Posterolateral is attached just lateral to
midline of the intercondylar eminence
• Fibres are most inferior on femur, most
posterior on tibia
• The bulkier posterolateral bundle is not
isometric
• ACL bundles are vertical and parallel in
extension
• Posterolateral bundle is tight in extension
• Both bundles of ACL are horizontal at 90°flexion
Arnoczky, 1983
posterolateral
anteromedial
Posterolateral Bundle
• Oblique position of the
posterolateral bundle
provides more rotational
control than is provided by
the anteromedial bundle,
which is in a more axial
position
• Hyperextension and internal
rotation place the
posterolateral bundle at
greater risk for injury
Posterolateral Bundle
• It limits anterior translation,
hyperextension, and rotation
during flexion
• Femoral insertion site of the
postero lateral bundle moves
anteriorly
• Both bundles are crossed
• Posterolateral bundle loosens
in flexion
Anterior Cruciate Ligaments
• 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
ACL in Extension and 45°
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
• During isometric quadriceps
contraction
• ACL strain at 30°of knee flexion is significantly higher
than at 90°
• Tension in ACL is least at 40°to 50°of knee flexion
Hunziker et al., 1992; Covey, 2001
Anterior and Posterior Cruciate
• ACL
• Provides 86% of restraint to
anterior displacement
• PCL
• Provides 94% of restraint to
posterior displacement
• Hyperextension of the knee
develops much higher forces in
ACL than in the PCL
Posterior Cruciate
• PCL is the strongest ligament of
knee
• It tends to be shorter
• More vertical
• Less oblique
• Twice as strong as ACL
• Closely applied to the centre of
rotation of knee
• It is the principle stabiliser
Hunziker et al., 1992
Attachment of the PCL
• The tibial attachment of the
PCL was on the sloping
posterior portion of the tibial
intercondylar area
• Extended 11.5-17.3 mm distal
to the tibial plateau
• Anterior to tibial articular
margin
• Blends with periosteum and
capsule
Javadpour & O’ Brien, 1992
Posterior Cruciate
• Anatomically the fibres pass
anteriorly, 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
Frazer 1965; Hunziker et al.,1992
• .
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
• 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
Blood Supply of
Posteriro Cruciate Ligaments (PCL)
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
• Posterior articular branch of
tibial nerve
• Fat pad
• Supplies cruciates
• Synovial lining of cruciates
• Mechanoreceptors and pain
sensitive
Kennedy et al., Freeman & Wyke, 1967
Nerve Supply of IFP
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
• 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
Flexion
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
• 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
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 Ligament• 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
Medial Collateral Ligament (MCL)
or Tibial Collateral Ligament• It has a superficial and deep
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
Anatomy of anterior_cruciate_ligament_by- dr. armaan singh

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Anatomy of anterior_cruciate_ligament_by- dr. armaan singh

  • 1. Anatomy of Anterior CruciateAnatomy of Anterior Cruciate LigamentLigament By- Dr. Armaan SinghBy- Dr. Armaan Singh
  • 2. Anatomy of Knee Joint • The knee joint is the largest joint in the body • One of the most frequently injured • Synovial condylar joint • Knee has six degrees of freedom, three translations and three rotations • Flexion and extension occur between femur and menisci • Rolling occurs above the meniscus, • Rotation between menisci and tibia • Gliding below the meniscus
  • 3. Knee Joint • The mechanism of the injury is an important factor in determining which structure is damaged • Injury to the anterior cruciate ligament occurs in both contact and non contact sports • Females are more at risk particularly gymnastics, skiing, soccer volleyball and basketball • A rapid effusion into a joint after an injury is a haemarthrosis and, in 75% of cases, is due to rupture of the anterior cruciate ligament
  • 4. Close-Packed • Stable position • Surfaces fit together • Ligaments taut • Spiral twist • Screw home articular surface
  • 5. Least-Packed • Joint more likely to be injured least- packed • Capsule slackest • Joint held in this • Position when injured • Knee in 20°flexion
  • 6. Articular Surfaces • The femoral articular surfaces are the medial and lateral femoral 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 ACL
  • 7. 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 distally and posteriorly, wider in front than at the back Last, 1984 medial
  • 8. 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
  • 9. 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
  • 10. Tibial Superior Articular Surface • The medial facet, oval in shape, 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 medial
  • 11. • 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
  • 12. Tibial Superior Articular Surface • 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 anterior ACL lateral meniscus PCL
  • 13. Patella • Sesamoid bone • Thickest articular cartilage in body • Smaller medial facet • Q angle • Controlled by vastus medialis obliquus (VMO) and vastus lateralis obliquus (VLO)
  • 14. 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
  • 15. Capsular Ligaments • Quadriceps • Retinacular fibres • Patellar tendon • Coronary ligaments • Medial and lateral ligaments • Posterior oblique ligament
  • 16. 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
  • 17. 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
  • 18. Anterior and Posterior Cruciates • Anatomically named by their tibial attachments • Clinically, femoral attachments are called the origin • Cruciates are intracapsular but extrasynovial • Cross in the sagittal plane • 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 oblique popliteal ligaments ACL
  • 20. 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
  • 21. 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
  • 22. 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 • Passes upwards and laterally to the posterior aspect of medial surface of lateral femoral condyle ACL lateral
  • 23. Tibial Attachment • Tibial attachment is in a fossa in front of and lateral to anterior spine • 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 • Larger tibial than femoral attachment • Shape of the attachment to tibia varies Amis,1991 ACL Medial PCL Posterior meniscofemoral
  • 24. Femoral Attachment • ACL attached to a fossa on the posteromedial corner of medial aspect of lateral femoral condyle in the intercondylar notch • Femoral attachment of ACL is well posterior to longitudinal axis of the femoral shaft. • Femoral attachment is in the form of a segmented circle • Anterior border is straight, posterior border convex Arnoczky et al 1983
  • 25. Femoral Attachment • Attachment is actually an interdigitation of collagen fibers and rigid bone, through a transitional zone of fibrocartilage and mineralized fibrocartilage • Attachment lies on a line which forms a 40°angle with the long axis of the femur Muller, 1982; Frazer, 1975
  • 26. ACL Bundles • The ACL consists of a smaller anteromedial and a larger posterolateral bundle, which twists on itself from full flexion to extension • The posterolateral bundle is larger and longest in extension and resists hyperextension • The taut ACL is the axis for medial rotation of the femur, during the locking mechanism of the knee in extension Hunziker et al.,1992 ACL
  • 27. Anteromedial Bundle of ACL • Anteromedial bundle attached to the medial aspect of the intercondylar eminence of the tibia • Anteromedial fibres have the most proximal femoral attachment • Anteromedial bundle is longest and tight in flexion • Femoral insertion of the anteromedial bundle is the centre of rotation of ACL Arnoczky et al 1993 antero medial bundle
  • 28. Anteromedial Bundle • Anteromedial bundle has an isometric behaviour • Tightens in flexion, while the postero lateral bundle relaxes in flexion • Is more prone to injury with the knee in flexion • Anteromedial band is primary check against anterior translation of tibia on femur • When anterior drawer test is performed in usual manner with knee flexed • Contributes to anteromedial stability O’Brien, 1992
  • 29. Posterolateral Bundle • Posterolateral is attached just lateral to midline of the intercondylar eminence • Fibres are most inferior on femur, most posterior on tibia • The bulkier posterolateral bundle is not isometric • ACL bundles are vertical and parallel in extension • Posterolateral bundle is tight in extension • Both bundles of ACL are horizontal at 90°flexion Arnoczky, 1983 posterolateral anteromedial
  • 30. Posterolateral Bundle • Oblique position of the posterolateral bundle provides more rotational control than is provided by the anteromedial bundle, which is in a more axial position • Hyperextension and internal rotation place the posterolateral bundle at greater risk for injury
  • 31. Posterolateral Bundle • It limits anterior translation, hyperextension, and rotation during flexion • Femoral insertion site of the postero lateral bundle moves anteriorly • Both bundles are crossed • Posterolateral bundle loosens in flexion
  • 32. Anterior Cruciate Ligaments • 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
  • 33. ACL in Extension and 45° O’Brien, 1992
  • 34. 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 • During isometric quadriceps contraction • ACL strain at 30°of knee flexion is significantly higher than at 90° • Tension in ACL is least at 40°to 50°of knee flexion Hunziker et al., 1992; Covey, 2001
  • 35. Anterior and Posterior Cruciate • ACL • Provides 86% of restraint to anterior displacement • PCL • Provides 94% of restraint to posterior displacement • Hyperextension of the knee develops much higher forces in ACL than in the PCL
  • 36. Posterior Cruciate • PCL is the strongest ligament of knee • It tends to be shorter • More vertical • Less oblique • Twice as strong as ACL • Closely applied to the centre of rotation of knee • It is the principle stabiliser Hunziker et al., 1992
  • 37. Attachment of the PCL • The tibial attachment of the PCL was on the sloping posterior portion of the tibial intercondylar area • Extended 11.5-17.3 mm distal to the tibial plateau • Anterior to tibial articular margin • Blends with periosteum and capsule Javadpour & O’ Brien, 1992
  • 38. Posterior Cruciate • Anatomically the fibres pass anteriorly, 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 Frazer 1965; Hunziker et al.,1992 • .
  • 39. 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
  • 40. 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
  • 41. Blood Supply of Cruciates
  • 42. • 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 Blood Supply of Posteriro Cruciate Ligaments (PCL)
  • 43. 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
  • 44. • Posterior articular branch of tibial nerve • Fat pad • Supplies cruciates • Synovial lining of cruciates • Mechanoreceptors and pain sensitive Kennedy et al., Freeman & Wyke, 1967 Nerve Supply of IFP
  • 45. 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
  • 46. 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
  • 47. 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
  • 48. 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
  • 49. • 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 Flexion
  • 50. 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
  • 51. 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
  • 52. Anatomy of the Menisci • 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
  • 53. 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
  • 54. 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
  • 56. 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
  • 57. Medial Collateral Ligament (MCL) or Tibial Collateral Ligament• 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
  • 58. Medial Collateral Ligament (MCL) or Tibial Collateral Ligament• It has a superficial and deep 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
  • 59. 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