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7411 Chap01
7411 Chap01
Chapter
Anatomy of the Knee
The human knee evolved from that of Eryops, the common ancestor of rep-
tiles, birds, and mammals, over 320 million years ago. The Eryops knee was
bicondylar, with a femorofibular articulation, cruciate ligaments, and asym-
metric collateral ligaments. As evolution continued, the fibula migrated dis-
tally and the femur articulated with the tibia. The osseous patella was a later
development, occurring about 70 million years ago. At that time the anterior
femoral condyle extended proximally beneath the patella to form the sulcus
and completed the development of the patellofemoral joint. This evolution-
ary process led to the development of the knee, the human hinged joint.1−3
The embryonic development of the human knee joint begins with limb
buds, whose earliest appearance is in week 4. These limb buds are formed
from somatic mesoderm covered by an ectodermal layer. The somites dif-
ferentiate into three segments: the dermatome, which becomes skin; the
myotome, which becomes muscle; and the sclerotome, which becomes car-
tilage and bone. The earliest signs of the knee joint appear in week 6, as the
femur and tibia arise as a cartilage anlagen. At this time chondrification of
the femur, tibia, and fibula begins along with the early differentiation of the
patella and patella tendon. The collateral ligaments and cruciate ligaments
form in week 7, by week 10 the medial meniscus can be seen, and differen-
tiation continues with increased vascularity up to the 40th (full term) week.
At the end of the embryonic period, the knee resembles the adult structure.4
∗ Department of Orthopaedics Surgery, Insall, Scott, Kelly Institute for Orthopedics and
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Bony Structures
The knee comprises three bones: the femur, tibia, and patella. The distal
femur has an asymmetric shape and is slightly cuboid. It provides areas of
attachment for the many ligaments and tendons about the knee (Fig. 1). The
medial epicondyle has a convex eminence in which the medial (tibial) col-
lateral ligament (MCL) attaches. The lateral epicondyle is smaller and less
prominent than its medial counterpart. It serves as the femoral attachment
for the lateral (fibular) collateral ligament (LCL).4 The epicondylar axis has
been defined, in normal knees, as a line that passes through the sulcus of the
medial epicondyle and the prominence of the lateral epicondyle. This line
in relation to the posterior condylar axis is externally rotated about 3.5◦ in
males and 1◦ in females.5
The tibia consists of medial and lateral condyles with which the dis-
tal femur articulates.4 The medial side is nearly flat, while the lateral side
is convex.6 The central aspect of the tibia has a spine that is between the
plateaus. This spine has a depression anteriorly that provides attachments
for the anterior horn of the medial meniscus, the anterior horn of the lat-
eral meniscus and the anterior cruciate ligament (ACL). Behind this are the
medial and lateral tubercles. These two structures do not appear to have any
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Fig. 1. (A–D) Tendon and ligament attachments about the knee. (Copyright 2006 by
Elsevier. With permission.)
attachments. Anteriorly, the tibia has a tubercle for insertion of the patella
tendon. Two-to-three centimeters lateral to this tubercle is Gerdy’s tubercle,
which is the insertion site of the iliotibial band (ITB).4
Finally, the patella is considered a sesamoid bone that articulates with
the trochlea of the distal femur. The articular surface is divided into a
medial and a lateral facet, with the lateral side being broader and deeper.
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Six different shapes of the patella have been described (Fig. 2). The first
two are considered stable, while the rest are considered variants that can
lead to instability. Considering the anterior position of the patella in the
extensor mechanism, the patella acts to protect the front of the knee and
increase leverage for the quadriceps femoris tendon.4
Soft Tissues
Muscles
The anterior aspect of the knee contains the quadriceps muscle group, which
comprises four distinct muscles with a common tendon insertion. The rec-
tus femoris muscle begins proximally as two heads from the ilium that
ultimately connect and form a muscle belly in the anterior thigh. It then
narrows to a tendon 5–8 cm above the patella. The vastus lateralis, the
largest muscle of the quadriceps group, begins as a broad aponeurosis at
the proximal part of the intertrochanteric line and extends to halfway down
the linea aspera on the femur. The distal aspect of the muscle has a fibrous
expansion into the lateral patellar retinaculum, which ultimately has con-
nections to the tibia. The vastus medialis may be divided into the vastus
medialis obliquus (VMO) and the vastus medialis longus. The fibers run
from the lower half of the intertrochanteric line to the medial lip of the
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linea aspera. The VMO fibers arise more distally and are more oblique
in orientation, varying from 55◦ to 70◦ relative to the longus fibers. The
distal insertion is similar to the lateralis, with a fibrous expansion into the
medial patellar retinaculum. Finally, the vastus intermedius originates at
the anterior and lateral shaft of the femur. The quadriceps insertion into the
superior border of the patella is trilaminar, with the rectus femoris respon-
sible for the most superficial layer, the vastus medialis and vastus lateralis
contributing to the middle layer, and finally the insertion of the intermedius
forming the deepest layer. This insertion extends over the patella and then
becomes the patellar tendon. The patellar tendon travels from the inferior
border of the patella to the tibial tubercle. It is a strong, flat band of tissue
that measures about 5 cm in length.4,7
The medial side of the knee contains the sartorius, gracilis, semi-
tendinosus, and semimembranosus muscles, as well as the medial head
of the gastrocnemius. The pes anserinus muscles (sartorius, gracilis, and
semimembranosus muscles) are the dynamic medial stabilizers, which flex
and internally rotate the knee. The lateral side contains the iliotibial band
(ITB), biceps femoris, popliteus, and lateral gastrocnemius muscles.4
Menisci
The menisci are two crescent-shaped structures that act to deepen the tibia
surface for articulation of the distal femur. They are composed primar-
ily of collagen (75%) and noncollagenous proteins (8–13%). Type I col-
lagen is the primary collagen and accounts for about 90% of the total
collagen.6 It is largely arranged in a circumferential pattern that aids in
absorbing compressive loads about the knee. There are also radial fibers
parallel to the plateau that provide rigidity and help to decrease longitudinal
splitting.8
Each meniscus covers roughly the peripheral two-thirds of the matching
articular surface of the tibia. The peripheral border of each meniscus is
thick, convex, and attached to the inside of the capsule of the joint. The
inner border is thin, concave, and has a free edge.4 The menisci serve
many functions, including load transmission by increasing the contact area,
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Fig. 3. Superior view of the tibial plateau. (Copyright 2006 by Elsevier. With permission.)
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into the adjacent capsule.4 Finally, the lateral meniscus has fibrous bands
called meniscofemoral ligaments. While the significance of these struc-
tures is not fully understood, they serve to connect the lateral meniscus
to the intercondylar wall of the medial femoral condyle. The ligament of
Humphrey passes anteriorly to the PCL, while the ligament of Wrisberg
passes posteriorly. Several cadaveric studies have concluded that the pres-
ence of these ligaments is quite variable, with the ligament of Wrisberg
appearing more often.11
Ligaments
The ACL is the primary static stabilizer of the knee against anterior transla-
tion of the tibia on the femur. It originates from the medial femoral condyle
at the posterior aspect of the intercondylar notch. The ligament then travels
in an anterior, distal, and medial direction toward the tibia (Fig. 4). It aver-
ages 38 mm in length and 11 mm in width. The primary blood supply is by
the middle geniculate artery. The posterior tibial nerve supplies branches
to innervate the ACL that appear to have a proprioceptive function.4,7,12
The ligament is twisted through 90◦ and both the length and the tension of
different fibers in the ligament change as knee flexion occurs. The antero-
medial bundle fibers become tight in 90◦ of flexion, while the posterolateral
bundle fibers are tight in full extension. These changes in fiber length cor-
relate with their changing participation in the total ACL action as the knee
is flexed and extended.7,13−15
The PCL is believed to be the most important of the knee ligaments
because of its cross-sectional area, tensile strength, and location in the
central axis of the knee joint. It provides about 95% of the total restraint
to posterior translation of the tibia on the femur. The tensile strength of
the PCL is almost twice that of the ACL.16,17 Like the ACL, the PCL is
a continuum of fascicles with different portions being taut throughout the
ROM. The anterior portion, which forms the bulk of the ligament, tightens
in flexion, and the smaller posterior portion tightens in extension.18
The PCL originates posteriorly in the intercondylar notch off the medial
femoral condyle. The average length is 38 mm and the average width is
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Fig. 4. Anterior and posterior views of the knee ligaments. (Copyright 2006 by Elsevier.
With permission.)
13 mm. The ligament travels posteriorly and distally to attach to the poste-
rior intercondyloid fossa of the tibia just posterior to the lateral meniscus,
1 cm below the articular surface. Lying anterior to the PCL, connecting the
posterior horn of the lateral meniscus to the medial femoral condyle, is the
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Fig. 5. (A, B) Medial structures of the knee. (Copyright 2006 by Elsevier. With
permission.)
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be the primary restraint on valgus stress and resists external rotation of the
tibia. The parallel fibers of the superficial MCL are under tension from full
extension to 90◦ of flexion but appear most taut from 45◦ to 90◦ of flexion.
The oblique fibers seem to have a minimal role in the overall function of
the superficial MCL. Finally, the deep MCL has only a weak, secondary
role in resisting valgus stress of the knee.20
The lateral knee has also been described in three layers. The most
superficial layer contains the iliotibial tract, biceps femoris, and peroneal
nerve. The second layer includes the patellar retinaculum and the lateral
collateral ligament (LCL). Finally, the third layer is the lateral part of the
joint capsule that is composed of a thin layer that circumferentially attaches
to the distal femur and proximal tibia23 (Fig. 6). The LCL itself is a strong,
round, fibrous cord which originates on the posterior part of the lateral
femoral condyle above the popliteus and inserts on the lateral fibular head,
just anterior to the styloid process.4 It is the major static support for varus
stress, whereas the iliotibial tract provides both dynamic and static support.
Next, the fabellofibular ligament is an expansion of fibers between the
LCL and the arcuate ligament. It runs from the fabella, a sesamoid bone
in the lateral head of the gastrocnemius, to the fibular head.24 The arcuate
ligament, also part of the posterolateral capsule, consists of the strongest and
most consistent fibers and forms a triangular sheet that extends proximally
from the fibular styloid. The lateral aspect of this is strong, with attachments
to the femur and popliteal tendon. The medial side is weaker and curves
around the popliteal muscle.
The popliteal muscle, included in layer 3, begins as a strong tendon
about 2.5 cm long from a depression anteriorly at the groove on the lateral
condyle of the femur. The tendon is surrounded by a synovial membrane
and passes under the arcuate ligament to form a flat, triangular muscle that
inserts on the posterior aspect of the proximal tibia. The primary function
of the popliteus appears to be to unlock the knee so as to allow flexion
by producing external rotation of the femur in the loaded position. These
structures, together with the PCL, act together to stabilize the posterolateral
corner against varus stress, posterior flexion, and external tibial rotation.6,25
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Fig. 6. (A, B) Lateral structures of the knee. (Copyright 2006 by Elsevier. With
permission.)
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Nerves
The innervation about the knee can be thought of by location. There is a
posterior group, including the tibial nerve and obturator nerve. Anteriorly,
there is the femoral nerve, common peroneal nerve, and saphenous nerve.
The tibial nerve begins as a branch from the sciatic nerve in the pos-
terior aspect of the thigh. It runs distally through the popliteal fossa and
then continues in the interval between the two heads of the gastrocnemius
(Fig. 7). The sural nerve, a cutaneous branch, travels on the surface of
the gastrocnemius. The tibial nerve also has many muscular and articu-
lar branches. The largest articular branch is the posterior articular nerve,
which most consistently arises within the popliteal fossa and then trav-
els laterally to join the popliteal plexus. Fibers from this plexus penetrate
through the oblique popliteal ligament to innervate the posterior and per-
imeniscal capsule and synovial covering of the cruciates. There is some
evidence that the meniscus has innervation into the peripheral third of the
Fig. 7. Posterior view of the knee. (Copyright 2006 by Elsevier. With permission.)
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Blood supply
The femoral artery descends the anterior thigh through the adductor canal.
This canal is bounded by the vastus lateralis in front and laterally and behind
by the adductor longus and magnus. Before passing through the canal,
the femoral artery becomes the descending genicular artery. This artery
then splits into a saphenous branch and an articular branch. The saphenous
branch accompanies the saphenous nerve to the medial side of the knee
and passes between the sartorius and the gracilis before connecting with
the medial inferior genicular artery. The articular branch descends within
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Fig. 8. Circulation and anterior anastomosis of the knee. (Copyright 2006 by Elsevier.
With permission.)
the vastus medialis and then forms an anastomosis with the medial superior
genicular artery and anterior recurrent tibial artery.4
The popliteal artery is the continuation of the femoral artery after it
exits the adductor canal, before entering the popliteal fossa. It continues
superficially to the popliteus fascia and then separates at the lower bor-
der of the popliteus into the anterior and posterior tibial arteries. It splits
into many muscular branches and five genicular arteries: medial superior,
lateral superior, middle, medial inferior, and lateral inferior.4 While all
four medial and lateral genicular branches supply blood to the menisci,
a majority comes from the superior and inferior lateral geniculates. Only
the peripheral third receives this blood supply. The middle genicular artery
splits into branches that pierce the synovium and form a plexus that covers
the ACL and PCL. These branches then anastomose with vessels that run
parallel to the collagen fibers.28
The anterior anastomosis around the knee is formed by the two medial
and the two lateral genicular branches, the descending genicular, the
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descending branch of the lateral femoral circumflex, and the anterior recur-
rent tibial (Fig. 8). This anastomosis essentially connects the femoral artery
with popliteal and anterior tibial arteries. It encircles the patella and then
splits into nutrient vessels at the inferior pole of the patella that ascend prox-
imally on the anterior surface of the bone. While the anterior skin of the
knee receives blood from both the medial and the lateral side, the primary
vascular supply comes from the medial side.4,6,29
References
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