knee ligaments

By M. MounesOrthopedic Department Ain Shams University

It is loss of normal anatomical relationship of the knee component during the ROM.

In this session we In this session we will discuss :will discuss :

- Bony Anatomy - Knee Functional anatomy - Knee Blood and Nerve

Supply - Knee Kinematics

The knee is formed from three bones :

- Femur (Femoral

Condyle) - Tibia (Tibial Plateau) - Patella (Articular

surface)

Femoral Part :- Medial femoral condyle: * Taller than the lateral femoral

condyle * 25 degree convergent * It is longer by 1.7cm than the

lateral condyle in the outer circumference

* Asymmetry in length produces axial rotation of the tibia on the femur during flexion and extension

- Lateral Femoral condyle: AP diameter more than the medial

condyle 10 degree convergent

Tibial Part :

- The medial plateau is nearly flat or concave and has a larger surface area than the lateral plateau.

- The lateral plateau surface is slightly convex.

- Both plateaus have a 10-degree posterior inclination to the tibial shaft in the sagittal plane.

ConcaConcaveve

ConveConvexx

Tibial Part :

- Tibial spines (or tubercles) are bony elevations, function to stabilize the condyles from side-to-side motion.

- The interspinous area is

void of hyaline cartilage, as are the insertion sites for the meniscal horns and cruciates.

Patella:

• Largest sesamoid bone in the body (usually 3 - 5cm in length)

• Patella tendon to patella length usually ratio of 1:1 (+/- 20%)

• 10% of patients have complete supra-patella membranes and 75% will have at least one of the 3 plica's even if only as a remnant (supra-patella, medial patella or infra-patella)

• Ossification centre appears between 2 and 3 years of age but can be as late as 6 years

Patella:

It has 2 articular facets (Medial and lateral)But recently (7)According to the shape of the facet it is

classified to :

In this session we In this session we will discuss :will discuss :

- Bony Anatomy - Knee Functional anatomy - Knee Blood and Nerve

Supply - Knee Kinematics

Knee Stabilizers Knee Stabilizers are :are :

-Extra-articular Extra-articular StabilizersStabilizers

-Intra-articular Intra-articular StabilizersStabilizers

-Medial-Lateral-Postero-medial-Postero-lateral-Antero-medial-Antero-lateral-Arcuate complex

-Medial-Lateral-Postero-medial-Postero-lateral-Antero-medial-Antero-lateral-Arcuate complex -ACL-PCL-MFL-Menisci

-ACL-PCL-MFL-Menisci-Bone congruityBone congruity

-PropioceptionPropioception

It is formed from three It is formed from three layers (Warren Marshal):layers (Warren Marshal):

1- First Layer: Crural fascia investing sartorius & gastroc + Sartorius

2- Second layer : - Superficial MCL. - Posterior Oblique ligament - Semi-membranosus

3- Third Layer: - Deep MCL - Coronary ligament - Medial capsule

-Is the primary static restraint to valgus stress at full ext. and at 30 degree flexion.

Has two portions: * Superficial fibers (tibial collateral ligament) * Deep portion (medial capsular ligament)

-Both portions originate from the medial femoral epicondyle.

-The superficial MCL has two bundles : The anterior bundle vertically oriented fibers inserts just posterior to the insertion of the pes anserinus; The posterior bundle oblique fibers insert inferior to the tibial articular surface.

- The medial capsular ligament also has two bundles : The meniscofemoral The meniscotibial portions, which are attached to the medial meniscus through the coronary ligaments.

The five attachments of the semimembranosus muscle :

-Direct head to the postero medial part of proximal tibia (pars directa)-Deep head deep to MCL (Pars reflexa)-Posterior oblique ligament-Oplique poplitial ligament-Expansions covering the popliteus fascia and the leg fascia

The five attachments of the semimembranosus muscle :

-Direct head to the postero medial part of proximal tibia (pars directa)-Deep head deep to MCL (Pars reflexa)-Posterior oblique ligament-Oplique poplitial ligament-Expansions covering the popliteus fascia and the leg fascia

Long Medial collater

-POL Attaches to PHMM & femoral condyle.

-Recently it is believes to be attached to SM and considered as one of its attachement

-It restraints Anterior tibial translation and external rotation through its attachment to the PHMM and Semimembrenosus

-POL rupture with the ACL when tibial anterior dislocation together with meniscal tear.

-POL rupture with the ACL when tibia external rotation

-Due to its parallism to PCL it acts secondary restraint of PCL

It is formed of three It is formed of three layers :layers :

1- First layer : Biceps femoris Iliotibial band2- Second layer : Patellar retinaculum Patello femorla ligament3-Third layer :LCL Popliteus tendonPopliteofibular ligamentPopliteomeniscal fasicle Arcuate ligamentFabillofibular ligamentPosterior capsule

Arcuate Complex:1]LCL2]. Arcuate lig (Y shaped condensation)3]. Popliteus tendon4]. Biceps tendon5]. Lateral head gastroc

PoplitePopliteus us CompleComplexx

1st Layer Ilial Tibial Tract

Bicep Femoris Peroneal Nerve

Exposing Layer 3

Deep Lamina of Layer 3

PF lig.

2° varus stabilizer Superficial Deep

(Kaplan’s fibers) Capsuloosseous

(anterolateral sling)

1° varus stabilizer Proximal / posterior

to lateral epicondyle Midway along fibular

head Surrounded by the

insertion of the Biceps muscle.

Stabilizer to posterolateral rotation1- Popliteus femoral

attachement

2- Popliteomeniscal fascicles

3- Popliteofibular ligament

4- Popliteal aponeurosis to lateral meniscus

Popliteofibular

Ligament

FabellofibularLigament

PopliteusMuscle

BicepsTendon

Popliteus attachment on Femur 2 cm from FCL Attaches on anterior fifth

of popliteal sulcus

Active internal rotator (unlocking)

Active antivarus joint coaptatorPassive control of external

rotationPassive control of

hyperextension

Originates at musculotendinous junction

Anterior / Posterior divisions

Static stabilizer of ER “Arcuate ligament” in old

literature

Fig. 8: Popliteofibular ligament, internal-external rotation (Karin Ullrich)

LCLLCL

Internal rotation tibia:lax

External rotation tibia:tense

It is formed from :-Anteromedial capsule- Medial retinacula-Patelofemoral and patelotibial ligament

It is formed from :-Anterolateral capsule- lateral retinacula-Iliotibial band

Knee Stabilizers Knee Stabilizers are :are :

-Extra-articular Extra-articular StabilizersStabilizers

-Intra-articular Intra-articular StabilizersStabilizers

-Medial-Lateral-Postero-medial-Postero-lateral-Antero-medial-Antero-lateral-Arcuate complex

-Medial-Lateral-Postero-medial-Postero-lateral-Antero-medial-Antero-lateral-Arcuate complex -ACL-PCL-MFL-Menisci

-ACL-PCL-MFL-Menisci

-Bone congruityBone congruity

-PropioceptionPropioception

Anatomy :Anatomy :Tibial origin : area approximately 11 mm X 17 mm located in front of, and lateralto, the medial intercondylar tubercleFemoral insertion :posterior part of the inner surface of the lateral femoral condyle

DimensioDimensions :ns :11 X33 mmThe ultimate load for the young ACL was 1,725 ±

269 N. Since that study, the criteria for the strength of autograft, allograft, and synthetic substitutes have been set at 1,730 N.

The ultimate load for the young ACL was 1,725 ± 269 N. Since that study, the criteria for the strength of autograft, allograft, and synthetic substitutes have been set at 1,730 N.

fUNCTIONS:fUNCTIONS:- Primary restrain to the anterior tibial displacement- Primary restrain for knee internal rotation- Secondary restrain to valgus and varus angulation at full extension-Propioception to the knee position -Screw home motion occurs around its axis

Direction of fibers :Direction of fibers :Anteromedial taut in flexion Posterolateral taut in extension

Named According to their insertion in the tibia

The secondary restrains to the anterior tibial drawer are :Medial meniscusCollateral ligamentsJoint capsule

AM taught in FlexionAM taught in Flexion

AM taught in ExtensionAM taught in Extension

Anatomy :Anatomy :Tibial origin :Femoral insertion :

DimensioDimensions :ns : The PCL averages in length between

32 and 38mm and has a cross sectional area of 31.2mm2 at its mid-substance level, which is 1.5 times that of the anterior cruciate ligament (ACL) cross-sectional area.Named according to Femur

Direction of fibers :Direction of fibers : The PCL consists of two functional components referred to as the anterolateral (AL) and the posteromedial (PM) bundles

It is the primary restraint to posterior tibial translation This is maintained throughout range of motion as the Anterolateral bundle is taught in flexion while the Posteromedial bundle is taught in extension.

fUNCTIONS:fUNCTIONS:

oPrimary restraint to posterior tibial translation oSecondary restraint to varus and valgus forces.o Secondary restraint to torsional forces.o Interacts with the ACL to form “Four bar cruciate linkage system”.oPropioception

They are :They are :

Ligament of HumpheryLigament of Humphery

Ligament of WrisborgLigament of Wrisborg

The ligament of The ligament of Humphry is anterior to Humphry is anterior to the PCL while the the PCL while the ligament of Wrisborg is ligament of Wrisborg is posterior to it.posterior to it.

Both arises from Both arises from the posterior horn the posterior horn of lateral meniscus of lateral meniscus and attached and attached anterior and anterior and posterior to the PCL posterior to the PCL attachment attachment simultaneously.simultaneously.

Ligament of Humphery

Ligament of Wrisborg

Anterior meniscofemoral ligament

Posterior meniscofemoral ligament

Elasto fibrocartilaginous Crescent shaped Medial meniscus is a small segment of a

wide circle while lat. meniscus is a large segment of a smaller circle

Ant. horns attached by a intermeniscal ligament

F is the highest vascular while A is the least vascular.

1 is the highest vascular while 3 is the least vascular

Popleteus muscle is attached to lateral meniscus

Semimemb. Is attached to medial meniscus Through the POL attachemetn to PHMM

Anterior horn of lat meniscus and post horn of both menisci attached to intercondylar eminence

Blood supply

From branches from lat,middle and medial genicular arteries

Vascular synovial tissue from the capsule supplies the peripheral third of the meniscus

Circumferential and radial collagen fibre type I in 98%

Matrix: Proteoglycans glycoproteins and elastins

Load bearing

At least 50% of the compressive load of the knee joint is transmitted through the meniscus in extension , and approx 85% of the load is transmitted in 90° flexion.Medial meniscus 85% LMM 75 %

Total meniscectomy can cause a fourfold increase in articular surface stresses.

Partial meniscectomy increases forces by 50%.

When compressive force is applied to the knee joint, the anterior and posterior attachments of the meniscus resist extrusion . This converts compressive force into hoop stress, which the circumferential orientation of the collagen fibers is ideally suited to withstand.

Load bearingThe shock absorbing capacity of normal knees is ~ 20% higher than in meniscectomised knees.

The ability of a system to absorb shock has been implicated in development of OA

It has a door stopper effect preventing anterior translation of the tibia

This has been inferred from the finding of type 1 and type 2 nerve endings in the ant and post horns of the menisci

• Secondary stabilizer• Proprioception• Joint lubrication

• Shock absorption

• Joint nourishment

The knee joint is a modified hinge synovial joint.

It is a combination of complex motion between rolling and gliding, ginglymus (hinge) and trochoid (pivot).

Hence comes the recent name (bicondyloid joint)

Six degrees of freedom are described to show the relationship of the tibia and the femur to each other.

These are broadly divided into:-Rotational - Translational.

The 3 rotational degrees of freedom are :1- Flexion-extension2- Internal-external axial tibial rotation3- Varus valgus (adduction-abduction).

The 3 translational degrees of freedom are: 1- Anterior-posterior tibial displacement2- Medial-lateral tibial displacement3- Proximal-distal (joint distraction-compression).

Constraints to excessive degrees of motion in these freedoms are provided by ligamentous structures around the knee.

How does the knee move ?

Differs from

How can the knee move ?

It is does not Roll

It is does not Glide

GLIDES

KINEMATIC THEORIES

1) Rolling Back of the femur

3) Helical axis

4) Envelope of motion

5) Rotation with medial pivot

2) Four-bar kinematic chain

6) Screw Home motion

MED LAT

Roll-back of femoral condyles

1) Rolling Back of the femur

Strasser, Lehrbuch der muskel, 1917

Four-bar chain is not rigid(PCL is lax in early flexion)

Zuppinger, Die active flexion, 1904

Four-bar chain is rigid

“Interactive knee”

2) Four-bar kinematic chain

(A) Model of the knee joint in full extension. (B) The interaction between these four bars can be used to describe theposterior migration of the tibiofemoral contact point that occurs with knee flexion. (C) Model of the knee joint in flexion.

Roll-back & Four-bar

Axis of motion passes through

the intersection of the bars

At the beginning the ratio of femoral to tibial motion is 2:1

At the end the ratio of femoral to tibial motion is 4:1

The angle of fixation of the four bar cruciate linkage system denotes the range of flexion and extension

If axis of fixation (blumenstate line) to the femoral axis is 90

degree

If axis of fixation (blumenstate line) to the femoral axis is 40

degree

Burmester Curve

A third order curve defined by the four bar cross linkage system defines the position for most isometric ligaments.

Burmester Curve

i.e. Points which make the external ligaments taught during flexion and extension thus maintaining its isometericity.

Knee flexion – Squatting (degrees)

15012510075502525

103) Rotation with medial pivot

MFCMFC

Does not move AP Does not move AP

Moves backward 19 mm

Freeman, JBJS-B, 2000

DEEP FLEXION

MEDIAL LATERAL

AND NO ROTATIONAL AND NO ROTATIONAL MOVEMENT OF THE MOVEMENT OF THE

MFCMFC ? ?

“Mobility” of the LATERAL femoral condyle is due to:

1) High mobility of lateral meniscus

2) Lateral tibial plateu

convex and downsloped

“Stability” of the MEDIAL femoral condyle is due to:

1) Restraint of the fixed posterior horn of medial meniscus

2) Medial tibial plateu

cup-shaped & “upsloped”

MFCLFC

MCLPCL

3) Ligament colums in constant tension on MFC

Flexion & rotation are combined resulting in an oblique axis.

FLEX ROT COMBINED

4) Helical axis

Obliquity and posterior shift produce an helical

234576

Within the envelope the knee is “free” (2 D.O.F.), but towards its limits the joint is restrainedwith rotations coupled to F/E (1 D.O.F.)

5) Envelope of motion

0 20 40 60 80 100

2 SWING PHASE

STANCE PHASEFe

Knee flexion – Stair climbing (degrees)

Hams pull tibia back(rollforward)

PCL restrains hams(rollback with flexion)

• It is the lateral rotation of the medial tibial plateau on femur during stance phase (extension), and internal rotation during swing phase (flexion).

• 3 factors leads to this mechanism:

1]. The more distal alignment of the MFC2]. The bigger radius of curvature of the MFC3]. The cruciates crossing in-between; around which this rotation occur

• Its significance it that it tightens both cruciates and locks the knee in the position of maximal stability

6) Screw Home motion

Valgus + External Rotation is the commonest medial side injury, respectively;1]. MCL then Medial capsule2]. ACL3]. MM = “O'DONOGHUE UNHAPPY TRIAD”

Varus + Internal injury of lat ligaments of the knee;1]. LCL then lateral capsule2]. ACL3]. Arcuate complex4]. Popliteus tendon5]. ITB6]. Biceps femoris7]. Common peroneal nerve,

HYPEREXTENSION mechanism:1]. ACL2]. PCL & posterior capsule

• ANTERO-POSTERIOR DISPLACEMENT: e.g. dashboard accident:1]. ACL or2]. PCL

A knee dislocation is an injury that involves the anterior curciate ligaments and the posterior curciate ligaments usually in combination with the medial collateral ligaments or the lateral collateral ligaments and associated soft tissue structures.

Recently knee dislocation can occur with one curciate in association with collaterals

MEDIAL DISLOCATION LATERAL DISLOCATION

ANTERIOR DISLOCATION POSTERIOR DISLOCATION

KD I : One of the cruciates + one of the collaterals

KDII: Both cruciates

KDIIIL : Both cruciates + LCL but MCL is Intact

KDIIIM: Both cruciates + MCL but LCL is intact

KDVI: Both cruciates + MCL + LCL

KDV: Fracture Dislocation knee

Knee fracture-dislocation (Fx-Dx)KDV.1 Fx-Dx ACL or PCL intactKDV.2 Fx-Dx with a bicruciate injuryKDV.3 Fx-Dx, bicruciate injury, one cornerKDV.4 Fx-Dx, all four ligaments injured+ N = Nerve injury+ C = Vascular injury

History:1- Ask about the traumatic knee event :

•Clear pop + Non contact trauma : - ACL - Patellar Dislocation •Clear pop + contact trauma: - Collateral - Fracture - Meniscal•No clear ‘pop’ PCL

2- Ask about the ability to continue walking :• If the pt. can continue Meniscal injury / PCL•If pt. can not Other ligamentous injury

3-Ask about Knee Swelling :• If immediate swelling Ligamentous injury Fracture•If late swelling meniscal injury

4-Locking:• Meniscal injury (Bucket hundle)•Lose body

5-Pseudo Locking:• Hamstring spasm•Hge + PF disorder

7- Pseudo giving way:• Reflex inhibition of muscles due to ant. Knee pain

6- Giving way:• Ligamentous injury•Patellar dislocation

Inspection & palpation :- Knee swelling, bruising.- Varus or valgus malalignment- ROM- Gait abnormality

- Ballottement test

-Wave test

- Quadriceps wasting and decrease in thigh girth

MCL and LCL:

leg under arm, 2 hands, 30º flexion to relax pos capsule (careful not to rotate knee)

• Valgus stress in flexion ........... MCL

• Valgus stress in extension …... MCL + POL

• Varus stress (taut in full ext) .... LCL (normally lax in flexion)

Grade 1 •Mild tendernes over the ligament. •Usually no swelling. •When the knee is bent to 30 degrees and force applied to the inside of the knee pain is felt but there is no joint laxity.

Grade 2•Significant tenderness on the lateral lig. •Some swelling seen over the ligament. •When the knee is stressed as for grade 1 symptoms,there is pain and laxity in the joint, although there is a definite end point.

Grade 3•This is a complete tear of the ligament. •When stressing the knee there is significant joint laxity. •The athlete may complain of having a very unstable knee.

-Knee flexed at 90° -Anterior pull of the tibia.

Anterior drawer Anterior drawer test :test :Anterior drawer Anterior drawer test :test :

- At 15-30º (put patient's knee over your knee) - most sensitive

Lachman test :Lachman test :Lachman test :Lachman test :

Laxity test

Functional tests

KT 1000 and KT 2000KT 1000 and KT 2000

1- Mcintosh 1- Mcintosh testtest1- Mcintosh 1- Mcintosh testtest

Pivot Shift Pivot Shift Tests:Tests:Pivot Shift Pivot Shift Tests:Tests:

2- Lose test2- Lose test2- Lose test2- Lose test

Knee extended, valgus strain, foot internally rotated, if instability present, tibia is subluxed anteriorly. Now flex knee, clunk at 30º is +veNormal MCLand iliotibial band and torn ACL

knee & hip flexed 45º and the other hand thumb behind the fibula. ER and valgus the tibia + slow extension + push the fibula forward tibial condyle shifts or subluxes forwards in full extension.

Pivot Shift Pivot Shift Tests:Tests:Pivot Shift Pivot Shift Tests:Tests:

4- Anterior jerk off 4- Anterior jerk off testtest4- Anterior jerk off 4- Anterior jerk off testtest

3- Slocum 3- Slocum testtest3- Slocum 3- Slocum testtest

Patient lies on unaffected side, with unstable knee up & flexed 10º.Medial aspect of foot rests on table. Patient maintains ipsilateral pelvis rotated posteriorly30-50º. Knee pushed into flexion. Easier to do in heavy or tense patients.

This is considered the reverse of the classic pivot shift test as it starts from flexion to extension.

1- Ducking 1- Ducking testtest1- Ducking 1- Ducking testtest

2- Acceleration deceleration test 2- Acceleration deceleration test (Gallop Test)(Gallop Test)2- Acceleration deceleration test 2- Acceleration deceleration test (Gallop Test)(Gallop Test)

3- Single leg 3- Single leg jump testjump test3- Single leg 3- Single leg jump testjump test

PCL and PLC :

Step Off testStep Off testPosterior drawer testPosterior drawer test

External rotation recurvatum testExternal rotation recurvatum test

Dial testDial test

Postero lateral drawer testPostero lateral drawer test

Whipple Ellis testWhipple Ellis test

Quadriceps Active testQuadriceps Active test

Reversed pivot shift testReversed pivot shift test

PLC PLC TESTES

Step off test :

- Knee flexed at 90° -The medial tibial plateau normally lies approximately 1 cm anterior to the medial femoral condyle.

-This step-off, is usually reduced in the PCL-deficient knee

- It can easily be felt by running the thumb down the medial femoral condyle toward the tibia.

Posterior drawer test :

The posterior drawer was the most sensitive test (90%) and highly specific (99%).

-The patient supine, with the hip flexed to 45°, the knee flexed to 90°, and the foot in neutral position.

- A posterior- directed force is applied to the tibia, assessing the position of the medial tibial plateau relative to the medial femoral condyle.

Posterior drawer test :The posterior translation is graded according to the amount of posterior subluxation of the tibia (Noyes grading):

1-Grade I : Tibial translation between 1 and 5mm. 2-Grade II : Posterior tibial translation is between 5 and 10 mm, and the tibia is flush with the femoral condyles. 3-Grade III : This is seen when the tibia translates greater than 10 mm posterior to the femoral condyles.

Because it is important to accurately measure the posterior translation of the tibia to select a proper treatment, instrumental devices such as the KT-1000 (MedMetric) has been developed as adjuvant tool.

- Patient supine position.- Suspending the lower extremity in the extension while grasping the great toe.

The sensitivity of this test, as reported in the literature, ranges from 33% to 94%.

External Rotation Recurvatum Test :

Dial Test :

- The patient positioned prone or supine. - An external rotation force is applied to both feet with the knee positioned at 30° and then 90° of flexion.

-When compared with the uninjured side, an increase of 10° or more of external rotation at 30° of knee flexion, is suggestive of an isolated PLC injury.

- Increased external rotation at both 30° and 90° of knee flexion suggests a combined PCL and PLC injury .

Quadriceps active Test :- The patient supine and the knee flexed to 90°.

- The examiner stabilizes the foot, and the patient is asked to slide the foot down the table.

-Contraction of the quadriceps muscle results in an anterior shift to the tibia in the PCL-deficient knee. A shift greater than 2 mm is considered positive for PCL insufficiency.

Whipple and Ellis Test :

-The patient prone and the knee flexed at approximately 70°.

- Grasping the lower leg with one hand and posteriorly displacing the tibia by the other.

- This test avoids quadriceps contraction, Moreover, if there is an associate damage of posterior capsular structures, the foot moves during this test medially or laterally

Reverse Pivot Shift Test :

- The patient is supine and the knee is held, initially, in 90° of flexion.

- The examiner externally rotates and extends the knee.

- When positive, an anterior shift of the tibia will occur at approximately 20° to 30° of flexion. It usually signifies injury to the PLC mainly in addition to PCL injury.

Meniscal tests :Meniscal tests :1- Mcmurray test1- Mcmurray test2- Appley compression 2- Appley compression testtest3-Jerk test3-Jerk test4-Steinmen test.4-Steinmen test.MOST IMPORTANT MOST IMPORTANT TENDER JOINT LINETENDER JOINT LINE

Mcmurray test:

Appley compression distraction test:

I- Anteroposterior and Lateral views :

To evaluate for fractures and/or dislocation.

Mediolateral displacement

Segond`s Fracture

Avulsion of tibial spine indicating ACL avulsion

II- Axial radiography :

- Knee flexed 70 and X ray beam angled superiorly.

-The location of the tibia in relation to the femur as compared with the contralateral normal side.

-An axial press 18kg may be used to produce maximum posterior translation.

III- Stress Radiography :

-Divided according to the type of the force applied to : A) Manual Force Technique :

- Produced by examiner or weight loading 200-300 N (25-30 Kg). - Another method based on hamstring contraction.

B) Instrumented Technique :

Due to lack of standardized applied force, errors in knee flexion angle and tibial rotation, an instrumental applied stress force is produced.

One of the most commonly used is Telos device.

IV- The kneeling view (Barlet view ):

- The patient in the kneeling position applies a direct force which subluxes the tibia posteriorly. be calculated.

Normal ACL , PCL and Menisci on MRI presents

MRI was found to be 99% accurate and sensitive diagnosing the presence of ACL and PCL injury.

Primary Signs:

1- Change of signal2- Change of contour

Loss of Loss of continuity in continuity in three three successive successive cutscuts

Secondary Signs:

1- Change of signal2- Change of contour3- Buckling of 3- Buckling of ACL and ACL and posterior PCL posterior PCL line does not line does not intersect the intersect the posterior posterior femoral line.femoral line.

4- Posterior border of the lateral plateua in the most lateral cut is translated anterior to the LFC

MRI classification was first published by Gross et al.

Grade I : Intraligamentous lesion : High signal intensity within the ligament.

Grade II : Partial lesion: High intensity signal on the dorsal edge of the ligament. (Anatomical site of the posteromedial fascicle)

Grade III: Partial lesion : High signal intensity on the ventral edge of the ligament. (The anatomical site of the anterolateral fascicle.)

Grade IV: Complete lesion : No remaining fibres are detected. AL and PM fascicles at the site of injury show high signal intensity and are scarcely detectable.

Stallar Classification

Example of GIII tearExample of GIII tear

Discoid MeniscusDiscoid Meniscus

Bucket Handle Tear:

-Part of the meniscus in the intercondyler notch-Vertical cut in the coronal section-Double PCL sign in both Coronal and Sagital

Bucket Handle Tear:

-Part of the meniscus in the intercondyler notch-Vertical cut in the coronal section-Double PCL sign in both Coronal and Sagital

Osteochondral Lesion + MCLOsteochondral Lesion + MCL

The role of diagnostic arthroscopy The role of diagnostic arthroscopy is debatable as history taking, is debatable as history taking, clinical examination and MRI are clinical examination and MRI are sufficient for diagnosis.sufficient for diagnosis.

But other surgeons state that But other surgeons state that arthroscopy can provide further arthroscopy can provide further information which is useful.information which is useful.

Arthroscopy is done 2 to 3 weeks Arthroscopy is done 2 to 3 weeks after injury.after injury.

ISOLATED ACL ISOLATED PCL:

The PCL has high potential for spontaneus healing

If avulsion ORIF It depends on the grade: - GI and II

conservative treatement - GIII usually

accompanied with PLC so usually needs rsurgical interference for acut PLC repair then three weeks later PCL reconstruction

ACL has no potentional for spontaneus healing

If tibial avulsion ORIF

If midsubstance tear we should do ACL reconstruction

Preopertive physiotherapy phase I for three wks then ACL reconstruction

ISOLATED MCL: ISOLATED LCL :

1. MCL has a potentional healing as it is broad

2. According to the grade:

- GI and GII usually conservative using hinged knee brace and physiotherapy

- GIII needs open repair if early or reconstruction if late.

LCL has no potential for healing as it is cord like.

If grade I usually conservative

Grade II and III treated usually be LCL reconstruction

ACL+ COLLATERAL(S) TORN

PCL+ COLLATERAL(S) TORN

1. Collateral ligament heal.

2. Early ROM.3. Delayed ACL

reconstruction.4. If PLC injuried this

require early operative repair or reconstruction.

Treatment should be directed 1st to pcl

ACL+PCL1.rare2.good outcome3.Intact collateral make treatment

simplified.4.Early repair of PCL after ROM then

delayed ACL reconstruction or bicurciate reconstruction simultaneously.

PLC injuries

acute chronic

Isolated(rare)

Combined with cruciate injury

Isolated(rare)

repair PLC repair +/- augmentation

Cruciate reconstruction

PLC reconstruction

Cruciate reconstruction++

osteotomy if varus malignment

The Graft of choice should be :- Strong.- Should provide secure fixation.- Should be easy to pass.- Should be readily available.- Should have low donor site morbidity.

I- Graft Choice:

Types of grafts:1- Autograft:

Quadriceps tendon autograft : - It is self available- Having a suitable size- Has approximately three times the cross-sectional area of the patellar tendon.- Long enough.- Leaves no anterior knee pain at the graft harvest site.

That makes it an acceptable graft choice for PCL reconstruction specially double bundle technique and inlay method .

Patellar tendon autografts Causes anterior knee pain.

Hamstrings facilitate the arthroscopic method and can be split into two sets for the double-bundle technique.

2- Allograft :

Achilis tendon allograft graft is recommended :- The osseous portion of the graft- Has high tensile strength.- Size and length for easily splitting in -double bundle reconstruction.

3- Synthetic graft

4- Allograft with Synthetic graft augmentation.

Synthetic graft augmentation

30°, 70°, 4.5 mm telescope

Pump Shaver Fluoroscopy for driling the tibial tunnel Specific PCL tools

Equipments :

Distal fixation: post, endobutton, fliptag.

Aperture fixation: interf. screws & wedges.

II- Fixation Sites:

Advantages: Provides rigid fixation.Improves stability & isometry.

Decreases working length of the graft leading to less creep & relaxation.

Avoids graft tunnel motion

Early bone intergration and hence early walking .

Disadvantages:Potential risk of graft laceration or fracture.

Provides less stiffness. Windshield wipering

effect (A/P). Bungee cord effect

(sup/inf). May cause delayed

incorporation & tunnel dilatation leading to increased laxity.

The strength & quality of fixation may be improved by filling the canal or by hybrid fixation.

Aperture Aperture fixationfixation

Distal fixationDistal fixation

III- Fixation devices:

- Screw (biodegradable or Titanium- Endbutton or fliptag- Tranfix or RigidFix

- Staples

ACL Transtibial Method (Arthroscopic)

ACL Reconstruction

Steps:

-Graft Harvesting- Graft Preparation

-Notch Debridement- Tibial Tunnel

-Femoral Tunnel

Notch Debridement

Tibial Footprint

Tibial FootprintIn the center of ACL tibial

insertion

Tibial Tunnel

Femoral FootprintFemoral Footprint

For decades, the conventional transtibial technique has

been regarded as the gold standard for ACL reconstruction.

Femoral Tunnel

Transtibial tunnel always guide the Femoral Tunnel to vertical non anatomical OVER THE TOP position.

A nonanatomically positioned femoral tunnel is one of the most common causes of clinical failure

after ACL reconstruction, with 15% to 31% of athletes

complaining of pain, persistent instability, or an inability to return

to the previous level of competition

1- PORTALS

2- Femoral Footprint

Double Bundle ACL

Double Bundle Femoral Tunnels

Double Bundle Tibial Tunnels

Is there any benefit from

Double Bundle ACL

reconstruction ?

ACL With Navigation

System

Treatment Treatment of PCLof PCL

Indicatioins : 1- Partial rupture of the PCL 2- Less than 10mm of posterior tibial

displacement (i.e. Grade I, II) 3- Elongation of the PCL

Physiotherapy is very essential Physiotherapy is very essential for conservative treatment for conservative treatment including three phases .including three phases .

Objects of applying physical therapy for patients with PCL :

-Reduce swelling and knee pain

- Strengthen the quadriceps muscle.

-To stimulate the propioceptive sense.

-Sustain the elasticity of muscles around the knee.

-Let the patient know their condition so that they can adapt daily life.

The Following Physiotherapy Can be Applied For PCL and ACL

but with difference of the mode either accelerated (3months) or normal rehabilitation (6 months)

-Knee braces applied to all patinets and locked between 0 to 60 degrees.

-Weight bearing is allowed only partially up to 50% of body weight.

Stretching program for thigh and leg muscles.

- Propioceptive training is applied at the late 4th week of the injury.

- Quadriceps muscles to be strengthened with increasing loads.

- Co-contraction of quadricpes and hamstrings muscles (Closed kinetic chain exercise).

- Propiocetpive exercise continue.- Normal gait with full weight bearing to be allowed.

- Knee brace is still used to support the knee during light activities in the early phase II.

- Jogging straight forward, side by side, and backward direction.

- Performing advanced propioceptive training.

- Return to sport activity.

Indications for operative treatment are :

I- Avulsion PCL injuries either femoral of tibial avulsionsII- Grade III PCL injuries with significant instabilily: Due to the probability of occult PLC injury.III- Combined injuries : PCL+ ACL, PCL+ PLC, PCL+MCL

IV- Failure of conservative treatment.

Reduction and fixation of the avulsed fragment via either :

- Open technique - Arthroscopic technique

The choice of the fixation device depends mainly on the size of the avulsed fragment:

- Large (more than 20mm) cannulated screw

- Meddium sized (10 to 20mm) K wires

- Small sized (less than 10mm) wire sutures

I- Posteromedial approach :

II- Direct posterior approach :

Biceps Femoris

Small Saphenous vein

Common peroneal nerve

Lateral head Gastrocnemeus

Tibial nerve

Medial Head gastrocnemeus

Semimembronuses

Post. Joint Capsule

Sandra et al. 2007 have described an arthroscopic method PCL avulsion repair:

- Posterior triangulation for adequate visualisation for the avulsed PCL fragment.- Classic anteromedial and amterolateral ports for reduction of the fragment using tibial guide.- Stabilization of the fragment by temporarily guide wire through the tibial guide forming tunnel A. (The wire has 2 holes in its distal end)- Another two tunnels B and C are formed in the PCL crater 2cm medial and lateral to the tunnel A.

- Steel sutures wires are passed through tunnel B, C ,then passed through the holes in the guidewire in tunnel A, then the guide wire is pulled.There is 4 ends for steel sutures wires free at the anterior tibial side to be tied firmly.

Portals :

-The standard anteromedial and anterolateral portals.

- In addition to posteromdial portal.

Debridement of PCL Remnants fibers :Meticulous debridement of the PCL insertion firbres by a shaver through the posteromedial portal.

Tibial tunnel:

- Tibial C guide used

- Entry point just distal and medial to tibial tubercle.

- The guide passes medial to the ACL to the posterior tibia.

- The vascular structures protected by the PCL Elevator.

Femoral tunnel:

-It is helpful to leave the PCL femoral insertion fibers intact to outline the PCL foot print.

- For the anterolateral bundle it present in the anterior half of the femoral PCL insertion 8 to 9 mm from the articular surface.

- In double bundle technique the posteromedial bundle lies posterior and proximal to it.

Femoral Tunnel tunnel:

- Femoral guide is used.

-The femoral tunnels are marked with cautery.

- Then probed.

- Then 2 guide wires are passed through them and overdrilled.

Passage of the graft :

Fixation of the graft :-Anterolateral bundle is fixed to the femrol in 90 degree

frlexion.-The posteromedial bundle is fixed in 20-30 degree flexion.

Single Bundle Double Bundle

Position of the patitent:

Incisions :

-Posterior approach.-Postrerior.

Preparation of the inlay graft:A unitcoritical window is fashioned to fit the dimensions of the bone block.

-The graft bone plug is fixed with 4.5 mm cannulated screws.-Then the femoral ends are passed through the femoral tunnels to be either Single bundle or Double bundle.

Fixation of the graft and femoral passage:

Harner, et al (2000)Harner, et al (2000)

- Showed in their cadaveric study that the use of double bundle technique reduced the posterior laxity by 3.5mm.

Bergfeld et al (2005) - No statistical differences between the single-

bundle and double-bundle reconstructions were found at any angle of flexion

Disadvantges of the transtibial method includes :

- Neurovascular injury.(The most seriuos)

- Patients frequently retain grade I or II laxity (Residual laxity)

- Graft failure due to killer turn.

Advantages of tibial inlay method:

- Imrpoved biomechanical stability by using larger graft.

- Less risk to neurovascular structures.

- Avoid the “Killer turn” in transtibial method

Disadvantages of the inlay method includes:

- Change the position of the patient intraoperatively.

- Opening of the posterior capsule.- Longer time of operation.- Making additional skin incision at the

popliteal fossa.

Bergfeld, et al. (2001)

-A study on 6 pairs of cadaveric knees, 6 inlay method and 6 transtibial method. -After cyclic loading, the transtibial technique grafts became compromised and failed, that is because" killer turn” that the graft makes at the mouth of the transtibial tunnel.

MacGilliravay, et al. (2006) -Transtibial tunnel technique with quadrupled hamstring autograft group on 21 knees was used and the tibial inlay technique with bone–patellar tendon–bone autograft on 22 knees. -The study identified no significant differences between the transtibial and tibial inlay techniques, and satisfactory clinical and stress radiologic results were obtained in both groups

A- Complications from trauma :

-Associated ligamentous injury

-Associated meniscal and chondral complications.

-Associated bone injury

-Fixed posterior subluxation (FPS): * It is a posterior displacement of the tibia more that or equal to 3mm on anterior stress radiograph. * Reduction of the FPS is essential before any surgical interference as it adds more stresses on the graft and leads to its failure.

- FPS can be treated by using a Posterior Tibial Support splint.- The splint is worn during the night for 6-8 weeks.

1- Neurovascular iatrogenic injury : (The most serious)-In transtibial tunnel during

reaming.-Methods to avoide:

I- Use of oscillating drill.

II- Use PCL elevator as a protector

II- Use of tapered instead of square drill.

III- Intraoperative image intensifier.

IV- Formation of posteromedial safety incision. (best method)

2- Residual laxity : (The Most common)

Methods to avoid:-The use of strong graft-Correct tunnel placement-Correct graft tensioning-Secure graft fixation.

3- Loss of knee ROM

4- Medial femoral condyle osteonecrosis

6- Graft failure:Technical considerations to avoid it:I- Smooth well chamfered tunnel edges.

II-Anatomic positioning of PCL reconstruction tunnels to avoid acute angles.

III-Secure fixation.

IV- Treatment of FPS before surgery.

V- Postoperative immobilization in full extension for 4-6 weeks.

-Persistent posterior sag.- Prominent hardware.-BTB patellar tendon graft.-Suprapatellar synovitis.

8- Intraoperative iatrogenic fracture.

1- Acute 1- Acute Repair Repair (Direct (Direct Repair)Repair)

Acute repair techniques of posterolateral corner (PLC) injuries. A, Injuries to the critical structures of the PLC. B, A sequential acute repair of the deep structures (popliteus complex, lateral collateral ligament, and capsule) and superficial structures (biceps and iliotibial band).

2- Chronic 2- Chronic PLCPLC

A- Non anatomic A- Non anatomic repair :repair :A- Non anatomic A- Non anatomic repair :repair :

Primarily sling procedures Biceps Tenodesis (nonanatomic)

A- Non anatomic A- Non anatomic repair :repair :A- Non anatomic A- Non anatomic repair :repair :

Deficiency of LCL

reconstruction with

B-PT-B Deficiency of LCL figure of eight ST

Two tailed reconstruction of FCL / PFL and popliteus tendon

Biomechanically restores function of native ligaments

B- Anatomic repair B- Anatomic repair ::B- Anatomic repair B- Anatomic repair ::

Femoral tunnels (8 mm) Proximal 1/5 popliteus

sulcus (PLT) Proximoposterior to

lateral epicondyle (FCL) 7 mm interference

screws

Tibial tunnel (10 mm) AP from distomedial

Gerdy’s to popliteus musculotendinous junction

Fix with bioscrew/staple (60°, IR)

Warren method :

Is older method and resembles the previous anatomic mentioned technique

-Knee braces applied to all patinets and locked between 0 to 60 degrees.

-Weight bearing is allowed only partially up to 50% of body weight.

Stretching program for thigh and leg muscles.

- Propioceptive training is applied at the late 4th week of the injury.

- Quadriceps muscles to be strengthened with increasing loads.

- Co-contraction of quadricpes and hamstrings muscles (Closed kinetic chain exercise).

- Propiocetpive exercise continue.- Normal gait with full weight bearing to be allowed.

- Knee brace is still used to support the knee during light activities in the early phase II.

- Jogging straight forward, side by side, and backward direction.

- Performing advanced propioceptive training.

- Return to sport activity.

Zones of the Zones of the meniscusmeniscus

Long tears (more than 2.5 cm) heal poorly.• Tears that are known to cause locking or that

can be locked during surgery are known to have higher healing failure rates.

LengthLength

Pattern of Pattern of teartear•Vertical tears have better healing potential.

•Oblique & horizontal tears are less likely to heal.•Stable tears heal readily ( tears less than 1 cm, tears that can not be displaced more than 3 mm, and partial thickness tears.

•Non operative treatment :Non operative treatment : Indications :Indications :

•No history of locking, a block to extension,•No associated ACL injury•Partial-thickness tears•Incomplete radial tearsStable vertical longitudinal tears displacement less than 3mm and the length less than 10 mm in length do not need resection

A- PARTIAL MENISCECTOMY•Most meniscal tears are treated by arthroscopic partial meniscectomy. •The goal of partial meniscectomy is to remove only the unstable or pathologic portion, leaving as much healthy meniscal tissue as possible while avoiding an abrupt transition to the remaining meniscus.

•Partial meniscectomy is indicated for: -Radial tears not extending to the periphery.-Oblique tears (flap or parrot beak) -Horizontal cleavage tears-Degenerative tears -Irreparable vertical longitudinal tears that are more than 5 mm from the absolute periphery. (i.e. in WW zone)

B- MENISCAL REPAIR :

Indications for Repair : Location : We repair all tears in the red zone and most in the gray zone Nonmacerated , nondeformed fragments in the gray zone only. Tear pattern : Repair is indicated for vertical longitudinal tears not Longer than 1 cm and for radial tears that extend into the red zone. Tissue quality : We do not repair macerated and degenerative menisci. AGE : We routinely perform meniscal repair in patients up to the age of 45 years.

Accepted techniques include :

• Open repair.

• Inside-out arthroscopic repair

• Outside-in arthroscopic repair

• All-inside repair.

ArrowsArrows

Fast FixFast Fix

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