1 Introduction - To - The - Knee

Sales Training
Knees
Introduction
to the Knee
July 2001
About Your Zimmer Knee Program
This Zimmer training program on the knee This program book is divided into several related
introduces you to basic concepts relating to the chapters, each beginning with a pretest. If you
knee and knee replacement. This instructional do well on the pretest, you may choose to move
module includes: to the next chapter.
• Chapter 1: Introduction to the Knee
The content of each chapter will be divided into
• Chapter 2: Knee Structure and Function
a series of learning segments.
• Chapter 3: Knee Muscles and Motion
At the end of each chapter, review questions
In Chapter 1, you will study the historical
allow you to confirm that you have grasped
development of knee prostheses. You will
the key concepts.
also study the types of diseases that cause
knee damage and how arthroplasty meets the A number of new and old terms are used in
challenge of repairing the disease damage. this module. You should become familiar with
the pronunciation and meaning of these terms.
In Chapter 2, you will study the bones and other
These terms appear in boldface type at their first
structures of the knee joint. You will learn about
substantive occurrence, to remind you that they
the femoral, tibial, and patellar components of
are defined in a glossary. The glossary can be
the knee. You will study the soft tissue structures
found at the end of the module.
associated with the knee: i.e., ligaments, knee
capsule, and menisci.
In Chapter 3,, you will learn about the motions

that occur about the knee as well as the muscles
that cause such motion.
All of these basic concepts are important for you

to understand Zimmer knee products as well as
competitive products.
CONFIDENTIAL.
Do not reproduce. Training purposes/internal use only. 1
Introduction to the Knee
CHAPTER 1:
BEGINNINGS
1. Historical Perspective
2. Perspectives
CHAPTER 2:
KNEE STRUCTURE
AND FUNCTION
1. Joint Structure Overview
2. Articulations and Alignment
CHAPTER 3:
KNEE MUSCLES AND MOTION
1. Flexion/Extension
2. Axial Rotation
GLOSSARY
Copyright ©2000, Zimmer Inc. All rights reserved.

This program is not to be reproduced in any form
without written permission from Zimmer Inc.
The material contained herein, including text, charts,

graphs, figures, tables, etc., is meant for your educational
training only. It is not to be used in selling efforts or
distributed to anyone outside Zimmer Inc.
CONFIDENTIAL.
2 Do not reproduce. Training purposes/internal use only.
Chapter 1: Beginnings
OBJECTIVES
PRETEST
INTRODUCTION
1. HISTORICAL PERSPECTIVE
Interpositional Arthroplasty
Hemiarthroplasty
Total Knee Arthroplasty
2. PERSPECTIVES
The Patient
Key Decision Makers
Indications for Surgery
Extent of Damage
3. SUMMARY REVIEW
CONFIDENTIAL.
Objectives
Upon completing Chapter 1: Beginnings,
you should be able to:
1. Identify the three historical steps
to total knee arthroplasty
2. Identify patient needs met
by knee arthroplasty
3. Identify physician needs met
by knee arthroplasty
4. Identify causes of knee damage
necessitating knee arthroplasty
CONFIDENTIAL.
Pretest
This pretest is provided to let you determine 2. Using the patient’s own joint capsule
what you know and what you need to know. as a joint cushion is known as:
You are not expected to know all the answers ____ a. Hemiarthroplasty
to these questions when you start the program. ____ b. Interpositional arthroplasty
In fact, you might have many incorrect answers.
____ c. Total knee arthroplasty
By identifying the information you already know
and that which you don’t know, this self- 3. Which of the following bone surfaces
assessment pretest will allow you to approach may be replaced in hemiarthroplasty?
this chapter in the manner best suited ____ a. Distal femur only
to meet your own informational needs. ____ b. Proximal tibia only
____ c. Either distal femur or proximal tibia
For each of the 10 multiple choice questions
indicated, make ONE or MORE choices by ____ d. Both distal femur and proximal tibia
placing an “X” in the appropriate space(s). ____ e. None of the above
Following the questions, you will find an 4. Waldius developed the first hinged
answer key and directions for tailoring the total knees in:
study program to your specific needs. ____ a. 1950’s
____ b. 1960’s
1. Which of the following was the first attempt
____ c. 1970’s
at solving the problem of knee damage?
____ a. Hemiarthroplasty ____ d. 1980’s
____ b. Interpositional arthroplasty

5. Covering the distal femur and proximal
____ c. Total knee arthroplasty tibia with a prosthesis is known as:
____ a. Hemiarthroplasty
____ b. Unicompartmental arthroplasty
____ c. Bicompartmental arthroplasty
____ d. Total knee arthroplasty
CONFIDENTIAL.
6. Metal femoral components and polyethylene 9. Medial/lateral instability is a characteristic of:
tibial components were first used by: ____ a. Slight knee damage
____ a. Campbell ____ b. Moderate knee damage
____ b.. Charnley ____ c. Severe knee damage
____ c. Gunston
10. The most common cause of knee damage
____ d. McKeever
requiring arthroplasty is:
____ e. Waldius
____ a. Osteoarthritis
7. In orthopaedics related to the knee, the major ____ b. Rheumatoid arthritis

factor bringing the patient to the surgeon is: ____ c. Trauma
____ a. Impaired mobility ____ d. Varus/valgus deformities
____ b. Pain
____ c. Impaired stability
8. The major indication for knee arthroplasty is:

____ a. Impaired mobility
Check your answers with the key on the
____ b. Pain
following page.
____ c. Impaired stability
CONFIDENTIAL.
PRETEST ANSWER KEY SECTIONS TO BE STUDIED
Compare your answers to the key below. Circle the section in which you had any incorrect
Circle each question you answered incorrectly. answers, then follow the directions below.
For questions with several correct responses,
Section 1 Section 2
you must have all correct.
Question Section
1. b 1
2. b 1
3. c 1 If you answered all questions correctly, turn
4. a 1 to the summary review questions on page 16.
5. c 1 If you answered 8 or more questions correctly,

6. c 1 complete each learning section you circled.
7. b 2 If you answered less than 8 questions correctly,
8. b 2 complete the entire unit.
9. c 2
10. a 2
CONFIDENTIAL.
Introduction
Think about your knees...not so much what they
look like, but what they do every minute of every
day. In the course of a “typical” day, how many
times do you bend your knees? How much
stress is placed on that joint? Do you have any
pain or discomfort associated with knee motion?
For many people, any activity that requires

knee motion causes pain or may simply be
impossible. In many cases, knee replacement
surgery will alleviate pain and restore mobility.
That’s where you come in. One facet of your
business includes the implants and instruments
for repairing or replacing the knee.
This Zimmer knee training program has

been designed to provide you with the
information necessary to understand and
explain Zimmer Knee Products, and to answer
and even anticipate, the physician’s questions
and concerns. Knowing your products and
what they do may mean the difference between
a relatively normal life and one of pain and
immobility for the patient.
As you work through this program, read the

material carefully. Answer the questions and
review material as needed.
CONFIDENTIAL.
1 Historical Perspective
To understand Zimmer Knee Products, INTERPOSITIONAL ARTHROPLASTY
a solid understanding of procedure and history
Interpositional arthroplasty was one of the
is in order. In this section, we will discuss the
earliest attempts at reconstruction of the knee.
historical development of knee replacement
It involved removal of damaged bone and the
surgery. As you will learn in Chapter 2, Knee
addition of some material between the two bony
Structure and Function, the knee joint includes
surfaces. The term “interpositional” refers to
surfaces of three bones, the:
placing something between the bones, to prevent
• Distal surface of the femur
fusion of the bones and to allow movement. The
• Proximal surface of the tibia
first step was taken by Ferguson in the 1860’s.
• Posterior surface of the patella
He removed the damaged bone at the articular
surface; however, he made no attempt to
Knee damage may involve any or all of these
“resurface” the remaining bone or to interpose
surfaces. Attempts to correct damaged surfaces
any material.
have been developed into surgical approaches
specific to the damage. In the evolution of
Verneuil improved the procedure by using
modern total knee arthroplasty (TKA), several
joint capsule material as a new articular surface.
different pathways have been explored:
This material cushioned the joint, reducing both
• Interpositional arthroplasty
wear and pain. Since the joint capsule material
• Hemiarthroplasty came from the same patient, it was called
• TKA “autologous” material. Later in the 1800’s and
early in the twentieth century, other autologous
Each of these approaches will be briefly
materials were used, including muscle, skin and
discussed, to give you a picture of the origins
fascia. In the 1920’s and 1930’s, Campbell
of TKA.
refined the technique, using fascia to cover
the surgically altered bones.
Other non-biological material, including

cellophane and nylon were also tried as new joint
surfaces, but were generally not successful.
CONFIDENTIAL.
HEMIARTHROPLASTY In the 1960’s, the focus of knee replacement
surgery shifted to the tibia. McKeever in 1960
As surgical techniques for hip replacement
and MacIntosh in 1963 introduced procedures
evolved, surgeons began to experiment with
that replaced the tibial surface with a metal
similar procedures for the knee. The next phase
prosthesis. Again, the solution was less than
in the development of knee replacement surgery
ideal. The unaltered femoral surface often
was hemiarthroplasty. “Hemi” means half and
caused continued pain. While the procedures
in hemiarthroplasty, one bone of the knee joint
in use at this time gave less than ideal results
is covered by a prosthesis. The surgeon uses
for many patients, the concept of covering
a metal or plastic component to cover the end
a defective femoral or tibial surface with a
of the surgically altered bone, creating a new
prosthesis had proven useful. Fixation of the
surface against which the other bone articulates.
implant with pegs and cement had further
The first hemiarthroplasties were done on increased the effectiveness of the procedure.
the femur. In the 1940’s, Campbell used a Those successes led to the next level
cobalt/chrome (CoCr) alloy prosthesis on the of development.
damaged distal femoral surface. Generally, distal
femoral replacement was not satisfactory.
However, surgeons from Massachusetts General
Hospital had better results after they added a
stem to the prosthesis.
CONFIDENTIAL.
TOTAL KNEE ARTHROPLASTY Gunston’s approach has led to two different
directions in knee arthroplasty. Separate medial
The earliest attempts to replace both surfaces of
and lateral components have ultimately led to
the knee with a hinged implant were as early as
unicompartmental designs. His more anatomic
Waldius’ procedure in the early 1950’s. His first
and multicentric design has also been
attempts used an acrylic implant, but by 1958 he
incorporated into components covering the
used a metal total-hinged knee. During the 50’s
entire femoral surface with one piece and the
other hinged knees were used and developed,
entire tibial surface with one piece. Covering
including those by Shiers and Guepar.
both the tibial and femoral surfaces has come
By 1960, it was apparent that the complex to be known as bicompartmental (two
motion of the knee puts too much stress compartment) arthroplasty. Finally, the major
and strain on a rigid hinged implant. In most contribution of the knee cap (patella) to knee
cases, the wear resulted in continued pain and function led to tricompartmental (three
loosening. Building on knowledge gained by compartment) arthroplasty in which the
the early knee replacements, Gunston in the posterior articular surface of the patella is also
early 70’s modeled a new knee approach on replaced with a prosthesis. Tricompartmental
Charnley’s low friction hip arthroplasty. On the arthroplasty therefore includes replacement of
femoral side, Gunston used two metallic pieces, the distal femoral articular surface, the proximal
one for the medial surface and one for the tibial surface, and the posterior patellar surface.
lateral surface. Two corresponding tibial Today TKA is usually tricompartmental.
components were of polyethylene. Gunston
cemented these components in place with
methylmethacrylate. The shapes of these
components were a first attempt to design
a prosthesis that could approximate the
mechanical multicentric movement of the
knee, which will be described in detail later
in this program.
CONFIDENTIAL.
2 Perspectives
Successful sales depend on your ability to match THE KEY DECISION MAKERS
your product benefits to the needs of the users/
A key decision maker is any one who may
buyers. Whose needs? Well, in selling prosthetic
influence the decision to buy a particular pros-
knees, the needs of several different individuals
thesis or prosthetic system. Depending upon the
and organizations must be considered.
particular institution, key decision makers may
include any combination of the following:
THE PATIENT • Physicians
Ultimately, the primary needs that must be met • O.R. staff
by a knee prosthesis are those of the patient. • Purchasing agents
A patient sees such needs in terms of reduction • Chief financial officer (CFO)
or elimination of symptoms. The patient would • Hospital administrator
consider his/her needs met when he/she
could recognize: The Physician.
• Pain relief The physicians’ (surgeon and any assistant
• Increased mobility surgeons) most immediate need is to meet the

needs of his patient. After surgery, the physician
• Improved stability
would expect to see:
Relief of pain is probably the major indicator for • Relief from pain
the patient of surgical success. Pain is probably • Good range of motion
what brought the patient to the surgeon in the • Stability
first place; pain is likely responsible to some • Long term fixation
extent for reduced mobility. The patient’s overall
goal is most likely resumption of a normal
daily life.
CONFIDENTIAL.
In addition, each physician has less obvious, but Purchasing Agents.
also important, personal needs. These include: Agents of hospital purchasing departments
• Maintenance of professional stature (ego) have a major cost concern. As a result, they are
• Compliance with institutional guidelines switching from purchasing and owning implant
• Compliance with government inventory. Instead, they are taking inventory on
directives (DRG’s) consignment and so don’t pay for the inventory

until they use it. They are seeking contract bids
• Technical accuracy
and vendor discounts to hold down prices.
• Ease of procedure
Chief Financial Officers (CFOs).
In general, physicians will want state-of-the-art
CFOs are also concerned about profitability,
technology in terms of design, instrumentation
including cost and reimbursement. Their
and surgical procedures. They will seek to
perspective focuses on the overall cost
minimize the risk of failure, both for their own
of the procedure, including:
and for the patient’s sake. Physicians may also
• Physician fees
have a strong allegiance to a particular company,
• Procedural fees (O.R. staff,
sales representative, or knee designer. In
O.R. medications, etc.)
addition, many physicians are quite aware
• Cost of implant
of the need to meet institutional and
governmental guidelines. Reimbursement includes:
• Patient out-of-pocket
Keep these considerations in mind as, later in
this program, features and benefits of Zimmer • Patient private insurance
Knee Products and procedures are discussed. • Federal and state government
(Medicare/Medicaid)
O.R. Staff.
• Other third party payers
O.R. staff (scrub nurses, circulating nurses,
and O.R. technicians) help ensure successful Hospital Administrator.
surgery and must be thoroughly familiar with Hospital administrators are concerned with
both the surgical procedure and the equipment. patient and surgeon satisfaction, but also with
They are concerned with delivery of the implant the overall cost of patient care.
before surgery and the ease of cleaning and
sterilizing implants and instrumentation.
CONFIDENTIAL.
INDICATIONS FOR SURGERY When knee damage from osteoarthritis is severe
enough, replacement is indicated. X-ray data are
Relief of pain is the major indication for knee
part of the picture, but the inability of the patient
arthroplasty, especially when that pain interferes
to continue a normal life style is even more a
with the patient’s day-to-day life. Such pain
factor in the decision to do an arthroplasty. As
usually develops as a result of damage to the
long as the patient can live fairly normally with
bone surface or supporting soft tissue. With
drug therapy, surgery is usually postponed.
more serious damage, stability of the knee joint
decreases, meaning a further reduction in knee Rheumatoid Arthritis.
function or motion. Rheumatoid arthritis is a chronic inflammation of
joints. Usually, joints are affected symmetrically,
A number of diseases or conditions are
that is, if the left knee is affected, the right is also.
commonly responsible for those symptoms
This condition usually begins with tissue
requiring knee arthroplasty. These predisposing
changes in the synovial membrane. As the
conditions will influence, to some extent, the type
disease progresses, the articular cartilage may
of prosthesis and the type of surgery. The most
begin to deteriorate. The bone itself may finally
common causes of knee damage include:
begin to erode.
• Osteoarthritis
• Rheumatoid arthritis Rheumatoid arthritis is an autoimmune
• Other arthritic conditions disease. As such it can currently be treated only
• Trauma symptomatically. If the knee is affected, as the

disease progresses, the knee joint becomes
• Varus/valgus deformities
more painful and less mobile. Replacement is
• Other congenital abnormalities
indicated when normal life becomes impossible.
Osteoarthritis. Because of the symmetrical nature of the
Osteoarthritis is a degenerative joint disease that disease, bilateral replacements are often needed.
often follows a history of injury or overuse of a
Varus/Valgus Deformities.
joint. It is characterized by cartilage degeneration
The angle between the femur and the
and eventual bone deformation, with or without
tibia is normally about 173 degrees. Should
inflammation of the joint. Motion is painful and
that angle decrease to 165 degrees or less
may eventually become impossible. In addition
(Fig. 1), the condition is known as a valgus
to degeneration of the bones, additional bony
deformity (technically known as genu valgum
material may be laid down in inappropriate
and commonly known as “knock knees”). This
places. These bony projections are called
malformation may be congenital (birth related)
osteophytes or bone spurs. Build up of extra
or due to disease or trauma. If the angle between
bony material can increase pain or decrease
joint mobility.
CONFIDENTIAL.
the femur and tibia increases to 180 degrees Minor.
or more, the condition is known as varus Minor damage refers to defects on the weight-
deformity (technically known as genu varum bearing (cartilaginous) surfaces of the knee.
and commonly known as “bow legs”). This
Moderate.
malformation also may be congenital or due
Moderate damage would include articular
to disease or trauma.
cartilage and bone damage, as well as anterior/
posterior instability. Anterior/posterior instability
results from soft tissue damage to ligaments and
other structures that hold the knee steady,
front to back.
Decreased Severe.
Angle
Increased
In the most severe cases, the patient has
Angle
defects on the weight-bearing surfaces, anterior/
posterior instability and medial/lateral instability.
As you might imagine, medial/lateral instability
results from soft tissue damage to structures
Valgus Varus that hold the knee steady from side to side.
Fig. 1 - Valgus/varus deformity.
In general, the surgeon will attempt to relieve
EXTENT OF DAMAGE pain and other symptoms with the least possible
surgical trauma to the patient.
The extent of knee damage is also important.
In fact, it can be a major factor in determining
the type of prosthesis needed. The following
presents one general way to view the degrees
of damage:
• Minor Now complete the following review questions.
• Moderate
• Severe
These correlate reasonably well with the types

of prostheses that may be used. However, the
decision to use one type of prosthesis depends
on assessment of the individual case, as well
as the physician’s perspective.
CONFIDENTIAL.
3 Summary Review
The following review questions will help you 6. List three patient needs to be met by
check your understanding and grasp of major prosthetic implants:
concepts presented in this chapter. Multiple a. _______________________________
choice and matching questions may have one b. _______________________________
or more correct responses. Be sure to write out c. _______________________________
your answers to completion and “explain”
7. List two (2) general physician needs:
type question.
a. _______________________________
An answer key is provided at the end of these b. _______________________________
review questions.
8. List four conditions that may cause knee
1. The earliest version of knee replacement damage and make total knee arthroplasty
surgery was interpostional arthroplasty. necessary:
Briefly describe what this term means: a. _______________________________
_________________________________ b. _______________________________
_________________________________ c. _______________________________
_________________________________ d. _______________________________
2. The procedure introduced by Campbell in the 9. A major factor in determining the type of
1940’s as an attempt to correct knee damage knee prostheses and surgery needed is:
was called: ____ a. Patient’s gender
_________________________________ ____ b. Extent of knee damage
____ c. Intensity of knee pain
3. How does hemiarthroplasty differ from total
knee arthroplasty?
10. Briefly describe the three levels
_________________________________
of knee damage:
_________________________________
_________________________________
_________________________________
4. The first total knee arthroplasties used what
_________________________________
type of prothesis?
_________________________________
_________________________________
_________________________________
5. Your knowledge of needs is important
in selling knee protheses. Why?
_________________________________
_________________________________
_________________________________ Check your answers with the answer key on the
following page.
CONFIDENTIAL.
SUMMARY REVIEW ANSWER KEY Section 2.
5. Successful sales depend on your ability
Compare your answers to the summary review
to match your products’ benefits to the
questions with the following answers. If you
patient and physician needs
missed any part of a question, count the entire
answer as incorrect. In essay type questions, 6. IN ANY ORDER:
your answers should be similar to those given • Improved mobility
in the key; the wording need not be exactly the • Reduced pain
same; but the meaning and the important points
• Increased stability
should be the same.
7. ANY TWO:
The section numbers indicate where the
• Meet the patient’s needs
“answer” information is discussed within
• Maintenance of professional stature
the chapter. Circle questions you have missed;
• Compliance with institutional guidelines
then turn back to the appropriate section(s) and
• Compliance with government
clarify the points missed before continuing with
directives (DRG’s)
the program. Also, rewrite the correct answer
for any question missed. • Technical accuracy
Section 1. 8. ANY FOUR:

1. The surgeon removed the damaged part of • Osteoarthritis
the bone and placed some type of material, • Rheumatoid arthritis
natural or man-made, between the bones to • Other arthritic conditions
prevent fusion and to provide a better surface • Trauma
for movement
• Varus/valgus deformities
2. Hemiarthroplasty • Other congenital abnormalities
3. In hemiarthroplasty, one side of the

knee (tibial or femoral) is covered with
a prosthesis. In total knee arthroplasty,
both sides of the knee joint, and the
posterior surface of the patella are
covered by prostheses
4. A hinged metal prosthesis
CONFIDENTIAL.
9. b
.
10. Minor damage refers to defects on the

weight-bearing (cartilaginous) surfaces
of the knee
In moderate damage, not only are the

articular cartilage and bone damaged, but
anterior/posterior instability is also present
In severe damage, the patient has

defects on the weight-bearing surfaces,
anterior/posterior instability and medial/
lateral instability
CONFIDENTIAL.
Chapter 2: Knee Structure and Function
OBJECTIVES
PRETEST
INTRODUCTION
1. JOINT STRUCTURE
The Bones
Soft Tissue
2. ARTICULATION
AND ALIGNMENT
Articular Surfaces
Compartments
Axes and Angles
Dynamic vs. Static Knee
Clinical Implication
3. SUMMARY REVIEW
CONFIDENTIAL.
Objectives
Upon completing Chapter 2: Knee Structure
and Function, you should be able to:
1. Identify the bones of the knee
2. Identify the structural landmarks
on the femoral side of the knee
on the tibial side of the knee
4. Identify the menisci and their
component parts
of the patella
6. Identify the ligaments of the knee
7. Label the axes and angles
of the knee joint
CONFIDENTIAL.
Pretest
This pretest is provided to let you determine 3. The tibial plateaus are found at which
what you know and what you need to know. end of the tibia?
____ a. Distal
You are not expected to know all the answers to
____ b. Proximal
these questions when you start the program. In
fact, you might have many incorrect answers. By 4. The tibial spine or eminence is located
identifying the information you already know and between the:
that which you don’t know, this self-assessment ____ a. Femoral condyles
pretest will allow you to approach this chapter
____ b. Femoral epicondyles
in the manner best suited to meet your own
____ c. Medial and lateral malleoli
informational needs.
____ d. Patellar facets
For each of the 20 multiple choice questions ____ e. Tibial plateaus
indicated, make ONE or MORE choices by
placing an “X” in the appropriate space(s). 5. Which bony component of the knee
is called a sesamoid bone?
Following the questions, you will find an ____ a. Femur
answer key and directions for tailoring the
____ b. Tibia
study program to your specific needs.
____ c. Patella
1. The knee is a hinged joint in:
6. The tendon of the quadriceps muscle
____ a. Appearance only
is attached to which part of the patella?
____ b. Actual motion only
____ a. Anterior superior surface
____ c. Both
____ b. Anterior inferior surface
____ d. Neither
____ c. Lateral facet
2. The “bony prominences” at the distal ____ d. Medial facet

end of the femur are known as:
____ a. Condyles
____ b. Epiphyses
____ c. Fibulae
____ d. Menisci
CONFIDENTIAL.
7. The articular surfaces of the tibia 12. Which of the following femoral structures
and the femur are cushioned by the: are knee articular surfaces?
____ a. Joint capsule ____ a. Lateral condyle
____ b. Ligaments ____ b. Lateral epicondyle
____ c. Menisci ____ c. Medial epicondyle
____ d. Muscles ____ d. Medial condyle
____ e. Tendons ____ e. Patellofemoral notch
8. Which of the menisci is relatively loose 13. The articular surfaces of the knee joint
and moveable? are composed of:
____ a. Lateral ____ a. Elastic cartilage
____ b. Medial ____ b. Fibrocartilage
____ c. Hyaline cartilage
9. A synovial membrane:
____ a. Attaches bone to bone 14. In the distal portion of the distal femoral
____ b. Attaches muscle to bone condyles, which of the following has the
____ c. Covers tendons narrower articular surface?
____ a. Medial condyle
____ d. Lines the joint capsule
____ b. Lateral condyle
____ e. Lines the menisci
15. Which of the following has the longer

10. Which of the following provides
articular surface?
anterior/posterior stability as well
____ a. Medial condyle
as rotatory stability?
____ a. Collateral ligaments ____ b. Lateral condyle
____ b. Cruciate ligaments

16. Which of the tibial articular surfaces
is larger?
11. How many articular surfaces are
____ a. Medial plateau
in the knee joint?
____ a. 2 ____ b. Lateral plateau
____ b. 4
17. Which of the tibial articular surfaces
____ c. 6 is convex?
____ d. 8 ____ a. Medial plateau
____ e. 10 ____ b. Lateral plateau
CONFIDENTIAL.
18. The transverse axis and the vertical axis
of the knee cross at:
____ a. 3 degrees
____ b. 9 degrees
____ c. 45 degrees
____ d. 87 degrees
____ e. 90 degrees
19. The knee is held firmly locked

as a result of the:
____ a. Collateral ligaments
____ b. Cruciate ligaments
____ c.. Joint capsule
____ d. Musculature
____ e. Screw home mechanism
20. In two-legged stance (static) position, the

transverse axis is parallel to the ground:
____ a. True
____ b. False
Check your answers with the key on the

following page.
CONFIDENTIAL.
Section 1 Section 2
Question Section
1. a 1
2. a 1
3. b 1 If you answered all questions correctly, turn
4. e 1 to the summary review questions on page 42.
5. c 1 If you answered 16 or more questions correctly,
6. a 1 complete each learning section you circled.
7. c 1
If you answered less than 16 questions correctly,
8. a 1
complete the entire unit.
9. d 1
10. b 1
11. c 2
12. a, d, e 2
13. c 2
14. a 2
15. a 2
16. a 2
17 b 2
18 e 2
19. e 2
20. b 2
CONFIDENTIAL.
Introduction
The structures of the knee are unique to allow
that joint to accomplish its job of movement and
stability while standing and moving.
You will need to know and understand the knee

structures and how they work in order to present
Zimmer prosthetic knee components to the
customers you serve.
As you work through this module, read the

material carefully. Answer the questions and
review the material as needed.
CONFIDENTIAL.
1 Joint Structure
The knee has been commonly called a hinged anatomy and motion of the knee provide for
joint. You can understand such a description both those functions. This section will focus
when you look at the knee in motion, as on knee structure. The details of knee motion
compared to the hip. Your hip swings in many (biomechanics) will be covered in detail in the
directions; the knee appears to move back and next chapter.
forth in one plane like a hinge. However, it is
only a “hinge” in appearance. The knee actually THE BONES
provides a complex interaction of gliding, rolling,
and rotational motions. This complex interaction The knee joint is made up of three bones, shown
is necessary for the knee to serve two opposing in Figure 2:
functions. When “locked in” or “screwed-home,” • Femur (distal end)
the position for standing (extension), the knee • Tibia (proximal end)
must provide a high degree of stability; it cannot • Patella
give way. Yet, in bending for movement such
In addition, a fourth bone, the fibula, while not
as walking, running, or climbing, the knee needs
physically part of the knee joint, plays a role in
flexibility and freedom of movement. The
stabilizing the knee.
Femur
Patella
Tibia
Fibula
Anterior Lateral
Fig. 2 - Bones of the knee.
CONFIDENTIAL.
The Femur. The shallow groove between the condyles on
As you can see in Figure 3, the distal femoral their anterior surface is called the patellar surface
shaft has two large convex bony prominences or patellofemoral groove.
called condyles. The inner, or medial femoral
This groove continues anteriorly at a slight
condyle is longer than the outer, lateral femoral
angle to the lateral side (“Q” angle) to allow
condyle. They also have different curvatures.
for normal tracking of the patella, shown in
The importance of this difference will be covered
Figure 4. This continuation is known as the
in Chapter 3, Knee Muscles and Motion. The
femoral trochlea..
bony prominences just anterior, above the
condyles are called the epicondyles - medial and
lateral. A line connecting the medial and lateral
epicondyles would travel at 3 degrees anteriorly,
from medial to lateral, in the coronal plane of the
femur. The position of the epicondyles may be
important to know if the condyles are so severely
“Q” angle
damaged that they cannot be used to position
a prosthesis. (This will be covered further in the
product modules). Between the distal portions
of the two condyles is a space (fossa) called
Extension Flexion
the intercondylar notch or intercondylar fossa.
Fig. 4 - Femoral trochlea.
Femoral
Shaft
Medial Lateral
Epicondyle Epicondyle
Femoral
Trochlea
Patellofemoral
Groove
Intercondyler
Notch
Medial Lateral
Femoral Inferior View Femoral Medial Anterior View Lateral
Condyle Condyle Condyle Condyle
Fig. 3 - Distal femur.
CONFIDENTIAL.
The Tibia. Distal Tibia.
Though the knee joint includes just the proximal The medial side of the distal tibia (Fig. 6) has a
tibia, the distal tibia is used as a reference point projection known as the medial malleolus. This
in knee arthroplasty. is the medial ankle bone. The lateral malleolus
is part of the distal fibula. Surgical instruments
Proximal Tibia.
used to align tibial cuts are usually attached just
The proximal tibia has two expanded surfaces,
above the ankle on the distal tibia. The tibial crest
the tibial plateaus. The medial tibial plateau
is pretty much the true center of the tibia; it can
articulates with the medial femoral condyle.
be found a few inches above the ankle.
In Figure 5, you can see that the two plateaus
are separated by a bony ridge called the tibial
spine or tibial eminence, which fits into the
femoral intercondylar space.
Fibula Tibia
Tibial
Eminence
Anterior View
Right Leg
Lateral Medial
Medial Lateral Malleolus Malleolus
Tibial Tibial
Plateau Plateau
Tibial
Tubercle
Medial
Plateau Tibal Lateral
Eminence Plateau
Fig. 6 - Distal tibia.
The Fibula.
As you can see in Figures 5 and 6, the fibula,
the second smaller bone of the lower leg, is not
actually part of the knee. The proximal tibia and
Tibial
Shaft proximal fibula do articulate, but is distal to the
Fibular
Shaft
knee joint. The fibula is involved in the knee joint,
however, primarily as the site of attachment for
Fig. 5 - Proximal tibia. a ligament needed for knee stability.
CONFIDENTIAL.
The Patella. a vertical ridge. That vertical ridge fits within
The patella is a short, flat, irregularly shaped the patellar surface (patellofemoral groove)
bone (Fig. 7). Occasionally, the patella is referred on the femur.
to as the sesamoid bone, referring to the shape
The inferior patellar ligament and the superior
of the bone, is rather like that of a sesame seed.
tendon of the quadriceps muscle (discussed
The patella is anterior to the tibiofemoral
later) are attached to the anterior surface
joint (Fig. 2).
of the patella.
The posterior surface of the patella is the
articular surface. It is divided into a medial and
lateral portion (the medial and lateral facets) by
Lateral Medial
Facet Facet
Posterior View Anterior View Lateral View

(Articulating Surface)
Fig. 7 - The patella.
CONFIDENTIAL.
SOFT TISSUE As you can see in Figure 8, one meniscus
is attached to each side of the tibial plateau –
Several soft tissue systems contribute to knee
lateral and medial. The horns of each meniscus
motion and/or knee stability, including:
are attached to the tibial eminences by the
• Menisci
coronary ligaments. On the anterior tibial
• Joint capsule
surface, the menisci are joined by a transverse
• Ligaments ligament. The medial meniscus is firmly attached
• Muscles to the tibia. The lateral meniscus is relatively
loose and moveable. Clinically, this means that
Menisci.
the medial meniscus is more prone to tearing
The menisci are two crescent shaped wedges
because it has less give.
of fibrous and cartilaginous (fibrocartilaginous)
material. The ends of the crescent are called
horns. They aid in distributing the body weight
load and other forces, acting as shock absorbers.
The menisci help deepen the socket somewhat,
perhaps contributing to stability.
Transverse
Ligament
Horn
Medial
Plateau
Lateral
Plateau
Lateral
Medial Meniscus
Meniscus
Fibular
Tibial Head
Eminence
Coronary
Ligament
Fig. 8 - Menisci.
CONFIDENTIAL.
Joint Capsule. Femur
The joint capsule is composed of a fibrous
connective tissue on the outside and the
synovial membrane on the inside. The capsule
is attached to the posterior surface of the patella
Patella
and completely envelops the femoral condyles
and the tibial plateau. This is illustrated sche-
matically in Figure 9. The fibrous portion helps
Condyle
hold the two bones together, and the synovial
lining produces the synovial fluid that lubricates
and nourishes the articulating surface.
Ligaments. Joint
Space
Ligaments are tough fibrous connective
tissue bands. Their primary function is to hold
the knee joint together and provide stability Capsule
Plateau (lined by
through the full range of motion (ROM). The the synovial
membrane)
two sets of knee ligaments, not including those
of the menisci, are called:
• Medial collateral ligament
• Lateral collateral ligament Tibia
• Anterior cruciate ligament

• Posterior cruciate ligament
Fig. 9 - Schematic diagram of the knee capsule –

sagittal section.
CONFIDENTIAL.
Femur
Anterior
Cruciate Ligament
Posterior
Cruciate Ligament
Lateral Meniscus
Lateral
Collateral Ligament
Medial Meniscus
Medial
Collateral Ligament
Tibia
Lateral View Posterior View
Fig. 10 - Ligaments of the knee.
Collateral Ligaments. Cruciate Ligaments.

Collateral ligaments (Fig. 10) are located on the The cruciate ligaments (Fig. 10) are so-called
lateral and medial aspects of the knee. The medial because they cross (forming an X-shape).
collateral ligament starts at the medial epicondyle The posterior cruciate ligament connects the
of the femur and attaches to the media aspect of posterior tibia to the posterior femur. The anterior
the proximal tibia. It is also attached to the medial cruciate ligament connects the anterior tibia
meniscus. The lateral collateral ligament connects to the posterior femur.
the femoral epicondyle to the proximal fibula.
It is not attached to the meniscus.
CONFIDENTIAL.
2 Articulation and Alignment
The geometry of the knee’s articulating ARTICULAR SURFACES
surfaces is very important for two reasons.
Altogether, the knee has six articular surfaces.
Each articulation essentially determines the
These six surfaces are distributed among
biomechanical function of the knee. Because
the three bony components of the knee:
of this, the geometry of the articulating surfaces
• Distal femur
must be taken into account in the design
• Proximal tibia
of prostheses and instruments for
knee arthroplasty. • Patella
Not only are the articulating surfaces important,

but so are their relationships to one another
and to the position of the overall femur and tibia.
Those alignments include the compartment of
the knee joint and the axes, planes, and angles
of the leg, thigh, and knee. This section includes
a basic description of:
• Articular surfaces
• Compartments of the knee
• Alignment
CONFIDENTIAL.
Distal Femur. Both condyles are rounded in two planes –
The distal femur has three of the articular a large convex curve sagittally (anterior to
surfaces (Fig. 11). They include the: posterior) and a smaller convex curve
• Medial femoral condyle transversely (medial to lateral). The medial
• Lateral femoral condyle condyle is a bit narrower on the distal end than
• Patellofemoral groove the lateral condyle, but it is also longer and
larger overall than the lateral condyle. However,
Both condyles are covered with articular from a lateral viewpoint, the distal femoral
cartilage. Articular cartilage is a special type curvature of the lateral condyle is larger than
of cartilage known as hyaline cartilage. It is the curve of the medial condyle, similar to
somewhat elastic, shiny, and bluish-gray in a pair of wheels, one larger (lateral) and
color. Damage to, or deterioration of, that one smaller (medial).
cartilage may lead to pain and can require
medical and/or surgical intervention for relief. If The patellofemoral groove is simply a groove
the fit between the patella and the patellofemoral on the anterior surface of the distal femur
groove is not right, pain may also result. between the two condyles. It runs laterally
in approximately 5 degrees of valgus, and it
accommodates the bony geometry of the
posterior patella surface.
Patellofemoral
Groove
Femoral
Trochlea
Patellofemoral
Groove
Medial
Femoral Lateral
Femoral Medial Lateral
Condyle
Condyle Condyle Condyle
Fig. 11 - Femoral articular surfaces.
CONFIDENTIAL.
Proximal Tibia. Medial Plateau.
The proximal tibia provides two of the The medial plateau is larger than the lateral
articular surfaces: plateau (Fig. 12). The medial meniscus sits on
• Medial tibial plateau this plateau. It is attached to the plateau by the
• Lateral tibial plateau medial coronary ligament and it is attached to
the lateral meniscus by the transverse ligament.
The medial plateau is biconcave in two
directions, that is, it is “dish-shaped” (Fig. 13).
Transverse
Ligament
Lateral Tibial
Medial Tibial Plateau
Plateau
Medial Lateral
Meniscus Meniscus
Tibial Tibial
Eminence Eminence
Fig. 12 - Tibial articulating surfaces.
CONFIDENTIAL.
Lateral Plateau. In the biomechanics of knee motion, the gap
The lateral plateau is somewhat smaller than the changes as the knee moves. Because of their
medial plateau. The lateral plateau is also shaped soft fibrocartilaginous structure, the menisci
differently – it is concave in the frontal section provide an additional articulating surface that
and convex in the sagittal section. It resembles changes as the gap between the tibia and
a “saddle” (Fig. 13). femur changes.
The femoral condyles do not exactly match the Patella.

two tibial plateaus, i.e., they are not congruent. The posterior surface of the patella articulates
(The importance of this will be shown later in with the patellofemoral groove as the patella
the program when you learn about the design moves up and down during movement
of knee prostheses). The gap between the at the knee.
femoral and tibial articulating surfaces is
filled by the menisci.
Lateral
Medial
Right Femur
Fig. 13 - Schematic of tibial articulating surfaces.
CONFIDENTIAL.
COMPARTMENTS Patellofemoral Compartment.
The patellofemoral compartment includes
The six articulating surfaces of the knee are
the anterior surface of the distal femur (the
divided up into three pairs. Each pair is referred
patellofemoral groove) and the posterior surface
to as a compartment:
of the patella. Movements in this compartment
• Medial compartment
are not as complex as those of the medial and
• Lateral compartment
lateral compartment. However, the pain caused
• Patellofemoral compartment by surface damage or misalignment can be as
serious as that associated with the other
Medial Compartment.
The medial compartment includes the articular two compartments.
surface of the medial femoral condyle, the medial

tibial plateau, and the medial meniscus.
Lateral Compartment.
The lateral compartment (Fig. 14) includes
the articular surface of the lateral femoral Lateral Medial
Compartment Compartment
condyle, the lateral tibial plateau and the lateral
meniscus. As you learned earlier, the smaller
Femoral
lateral meniscus has more freedom to move, Condyle Femoral
Condyle
compared to the larger medial meniscus.
Because the lateral meniscus has more “give,”
it is less prone to injuries. As a result,
meniscus tears are less common in Meniscus
Meniscus
the lateral compartment.
Tibial
Plateau
Tibial
Plateau
Fig. 14 - Medial and lateral compartments.
CONFIDENTIAL.
AXES AND ANGLES Mechanical and Anatomic Axes.
The mechanical axis (Fig. 15 -“M”) runs from
Look at your leg – the femur, knee, and lower
the center of the femoral head through the
leg. If you stand straight, assuming your knee
center of the distal femur, between the two
and hip are functioning normally, the bones of
condyles to the center of the ankle (Fig. 15 -“A”).
your leg and thus the joints are arranged at
The mechanical axis is tilted about 3 degrees
particular angles to each other. These angles are
laterally from the vertical axis.
similar to the angles of the bones in any normal
hip and knee. The concept of the axes of the
M V M A
femur are discussed in detail in the Hip Program.
6˚
Here we will summarize normal bone position
with respect to the knee.
Figure 15 shows the relative positions and the

3˚ 9˚
angles and axes of the femur and tibia. In the
Mechanical
diagram, the line marked “V” is the vertical axis, Axis
Femoral Shaft
a line perpendicular to the ground. This is used Axis or
Anatomic Axis
Vertical Axis
as a reference point in describing the axes
of these bones.
90˚
Transverse
Axis T
3˚ 3˚
A A
Fig. 15 - Axes and angles.
Note: In the tibia the mechanical axis and the

anatomic axis are identical.
CONFIDENTIAL.
The anatomic (shaft) axis of the femur Varus/Valgus Deformities.
(Fig. 15 – “A”) is different from its mechanical As you can see in Figure 15, the difference
axis. The anatomic axis is tilted 9 degrees between the vertical axis and the transverse axis
laterally from the vertical axis, and as a result is about 90 degrees. This means that the normal
the femur comes into the knee joint at an angle angle between the anatomic axis of the femur
of 9 degrees from vertical. and tibia is about 171 degrees, or about 9-10
degrees less than the vertical axis. If the angle
Note, however, that the mechanical and
decreases to 165 degrees or less, a valgus
anatomic axes of the tibia are the same,
deformity (genu valgum) exists, a condition
3 degrees off vertical.
known as “knock knees.”
The mechanical axis of the femur goes from

Should the knees move outward, i.e., should
the head of the femur through the center of
they bow, the angle between the vertical axis and
the intercondylar notch. Along this same axis,
the mechanical axis would be 180 degrees or
the mechanical axis of the tibia continues from
more. This is a varus deformity (genu varum)
the center of the tibial plateau to the center
commonly known as “bow legs.”
of the ankle at the distal end of the tibia,
maintaining 3 degrees from vertical all the way. If either of these two conditions exist, they
must be corrected by appropriate cuts when the
Transverse Axis.
prosthesis is placed. This is necessary to avoid
One more axis is also important, the
abnormal stress on the joint with subsequent
transverse axis. As you can see from Figure
failure of the prosthesis.
15, the transverse axis is a horizontal axis at
right angles to the vertical axis. When the thigh
and leg are positioned as shown in Figure 15,
the femoral condyles and tibial plateaus line
up straight across the transverse axis.
CONFIDENTIAL.
DYNAMIC VS. STATIC KNEE The term “static knee” refers to the knee
in supported stance. As shown in Figure 16,
These angles and axes are extremely important
the ankles are farther from the midline than
in reconstructive knee surgery. That importance
the hips. Notice what happens to the articular
becomes apparent when you consider the
surface across the femoral condyles and tibial
dynamic knee vs. the static knee (Fig. 16).
plateau. The plane is no longer parallel to
The dynamic knee refers to the position of the
the ground.
tibia, femur, and articular surfaces in walking.
The walking position is compared to the one- The screw home mechanism and the collateral
legged stance. In walking or one-legged stance, ligaments hold the knee locked when the knee is
the angles and axes are those shown in Figure in the static position. When the knee is replaced,
15. Notice, the ankles are closer to the midline the collateral ligaments must be tight enough
than the hips (Figs. 15 and 16). The articular to maintain that stability. If they are not capable,
surfaces are in the transverse plane, parallel the prosthesis must be designed to provide the
to the ground. stability. This screw home mechanism (or
automatic rotation) is covered in more detail
in Chapter 3: Knee Muscles and Motion.
Dynamic Static
Mechanical Mechanical
Transverse Transverse
One-legged Two-legged
Walking Supported Stance
Fig. 16 - Dynamic vs. static knee.
CONFIDENTIAL.
CLINICAL IMPLICATION If any combination of prostheses,
instrumentation and surgery places the
The axes and angles in dynamic vs. static
articulating surface in any other plane than
positions are extremely important in the design
the one nature intended, abnormal stress
of prosthetic knees. They are also extremely
distribution will result. Abnormal stress
important in instrument design, in preoperative
distribution is one of the major contributors
preparation and in implanting the prostheses.
to implant failure.
Prostheses, instruments, and surgical

procedures must restore the transverse
articulating plane for the dynamic knee.
It is only in that position that the knee can be
expected to function properly in any mobile Now complete the following review questions.
(ambulatory) patient.
CONFIDENTIAL.
3 Summary Review
The following review questions will help you 2. On the drawing below, identify the four
check your understanding and grasp of major bones associated with the knee. Place an
concepts presented in this chapter. Multiple asterisk (*) next to the three bones that
choice and matching questions may have one are actually part of the joint:
or more correct responses. Be sure to write a. _______________________________
out your answers to completion and “explain” b. _______________________________
type questions. c. _______________________________
d. _______________________________
An answer key is provided at the end of these
review questions.
1. With three single words, describe the a
actual movements that make up the overall

composite knee motion:
b
a. _______________________________
b. _______________________________
c. _______________________________
CONFIDENTIAL.
3. Identify the femoral knee structures 4. Identify the view and the tibial knee
indicatied below. Also indicate the view: structures indicated on the figure below:
a. _______________________________
b. _______________________________
a c. _______________________________
d. _______________________________
e. _______________________________
f. the view is_______________________
f
a
e
b
d
e
b
c
a. _______________________________
b. _______________________________
c. _______________________________
c
d. _______________________________ d
e. _______________________________
f. ________________________________
g. the view is_______________________
5. Which surface of the patella is its

articulating surface?
_________________________________
6. The patella articulates with what specific

structure, on which other knee bone?
_________________________________
7. Briefly describe what a meniscus is:

_________________________________
_________________________________
_________________________________
8. Which meniscus is more firmly attached?

_________________________________
CONFIDENTIAL.
9. What is the clinical significance of your 13. The lateral collateral ligament connects
answer to Question 8? which two bones?
_________________________________ a. _______________________________
b. _______________________________
10. The ends of the crescent-shaped menisci
are called: 14. Name the bony and cartilaginous
_________________________________ structures of the medial compartment:
a. _______________________________
11. The fibrous structure surrounding and
b. _______________________________
enclosing the joint space of the knee
c. _______________________________
is called a:
_________________________________ 15. Name the bony and cartilaginous
structures of the lateral compartment:
12. Identify the ligaments and other structures
a. _______________________________
indicated on the figures below:
b. _______________________________
a. _______________________________
c. _______________________________
b. _______________________________
c. _______________________________ 16. Briefly describe the shape of the articular
d. _______________________________ surface of the femoral condyles:
e. _______________________________ _________________________________
f. ________________________________ _________________________________
g. _______________________________ _________________________________
17. How does the medial femoral condyle

compare to the lateral femoral condyle?
_________________________________
a 18. Describe the shape of the medial tibial

b plateau in the:
c
f a. Frontal plane______________________
d g
e b. Sagittal plane_____________________
19. Describe the shape of the lateral tibial

plateau in the:
a. Frontal plane______________________
b. Sagittal plane_____________________
CONFIDENTIAL.
20. The tibial and femoral articulating surfaces 22. What is meant by the “dynamic” knee?
are not congruent (Their curves do not match _________________________________
point by point). What structures provide for _________________________________
this changing gap? _________________________________
_________________________________
23. What is meant by the “static” knee?
21. On the diagram shown below, label the axes _________________________________
and angles indicated: _________________________________
_________________________________
24. What is the position of the transverse

axis of the knee relative to the ground,
on an x-ray, taken with the ankles closer
together than the hips?
_________________________________
25. What is the position of the transverse

axis of the knee relative to the ground,
on an x-ray, taken in the typical
supported stance?
_________________________________
Check your answers with the answer key on the

following page.
CONFIDENTIAL.
SUMMARY REVIEW ANSWER KEY 3. IN THIS ORDER:
a. Femoral shaft
b. Medial femoral condyle
questions with the following answers. If you
missed any part of a question, count the entire c. Intercondylar notch
answer as incorrect. In essay type questions, d. Lateral femoral condyle

your answers should be similar to those given e. Patellofemoral groove
in the key; the wording need not be exactly the (patellar surface)
same; but the meaning and the important points f. Femoral trochlea
should be the same. g. Anterior
The section numbers indicate where the 4. IN THIS ORDER:

“answer” information is discussed within a. Tibial eminence (spine)
the chapter. Circle questions you have missed; b. Medial tibial plateau
then turn back to the appropriate section(s) and
c. Tibial shaft
clarify the points missed before continuing with
d. Fibula (fibular shaft)
the program. Also, rewrite the correct answer
e. Lateral tibial plateau
for any question missed.
f. Posterior
Section 1.
1. IN ANY ORDER: 5. Posterior
• Rolling
6. Patellofemoral groove
• Gliding
(patellar surface) of femur
• Rotation
7. A meniscus is a crescent shaped wedge
2. IN ANY ORDER: of fibrocartilaginous material located on
a. Femur* the tibial plateau (There are two – medial
b. Patella* and lateral)
c. Tibia*
8. Medial
d. Fibula
9. The medial meniscus is more prone

to tear (because it has less “give”)
10. Horns
11. Capsule
CONFIDENTIAL.
M V M S
6˚
12. IN THIS ORDER: 21.
a. Posterior cruciate ligament
b. Anterior cruciate ligament
c. Lateral collateral ligament 3˚ 9˚
d. Lateral meniscus Mechanical

Axis
e. Posterior cruciate ligament Femoral Shaft
Axis or
Anatomic Axis
Vertical Axis
f. Medial collateral ligament
g. Medial meniscus
13. IN EITHER ORDER:

• Femur 90˚
Transverse
Axis T
• Fibula
Section 2.
14. IN ANY ORDER:
• Medial femoral condyle
• Medial meniscus 3˚ 3˚
• Medial tibial plateau
15. IN ANY ORDER:

• Lateral femoral condyle
• Lateral meniscus
• Lateral tibial plateau A A
22. Dynamic knee refers to the walking knee.

16. In the sagittal plane, the femoral condyles
It represents the position of the thigh and leg
have a large convex curve; in the frontal
in a one-legged stance (or when both feet are
plane, they have a smaller convex curve
on the ground with ankles closer together
17. The medial condyle is a bit narrower than hips)
than the lateral, but longer
23. Static knee refers to the position of the knee
18. a. Concave in a two-legged supported stance
b. Concave
24. The transverse axis would be parallel
19. a. Concave to the ground
b. Convex
25. The transverse axis would not be at an
20. The menisci angle (not parallel) to the ground
CONFIDENTIAL.
Chapter 3: Knee Muscles and Motion
OBJECTIVES
PRETEST
INTRODUCTION
1. FLEXION/EXTENSION
Flexion
Extension
2. AXIAL ROTATION
External/Internal Rotation
Automatic Rotation
Freedom of Movement
Clinical Implication
3. SUMMARY REVIEW
CONFIDENTIAL.
Objectives
Upon completing Chapter 3: Knee Muscles
and Motion, you should be able to:
1. Identify the major motions of the knee
2. Identify the major muscle groups that

provide motion at the knee
3. Identify the major flexors of the knee
4. Identify the major extensors of the knee
5. Identify the major rotators of the knee
CONFIDENTIAL.
Pretest
This pretest is provided to let you determine 3. When the knee flexes normally, the range of
what you know and what you need to learn. motion is up to approximately:
You are not expected to know all the answers to ____ a. 60 degrees
these questions when you start the program. In ____ b. 80 degrees
fact, you might have many incorrect answers. By
____ c. 100 degrees
identifying the information you already know and
____ d. 110 degrees
that which you don’t know, this self-assessment
____ e. 140 degrees
pretest will allow you to approach this chapter
in the manner best suited to meet your own
4. Which of the following are flexors
informational needs.
of the knee?
____ a. Biceps femoris
For each of the 15 multiple choice questions
indicated, make ONE or MORE choices by ____ b. Rectus femoris
placing an “X” in the appropriate space(s). ____ c. Semi-membranosus
____ d. Semi-tendinosus
Following the questions, you will find an
____ e. Vastus lateralis
answer key and directions for tailoring the study
program to your specific needs.
5. Which of the following are extensors
of the knee?
1. Flexion at the knee involves which
____ a. Biceps femoris
of the following?
____ a. Gliding ____ b. Rectus femoris
____ b. Hinge-like motion ____ c. Semi-membranosus
____ c. Rolling ____ d. Semi-tendinosus
____ d. Sliding ____ e. Vastus lateralis
____ e. All of the above

6. The patella increases the moment arm
of the quadriceps muscle by about:
2. The center of rotation on the distal femur
____ a. 10%
during flexion is:
____ a. A single center ____ b. 20%
____ b. Bicentric ____ c. 30%
____ c. Multicentric ____ d. 50%

____ e. 75%
7. The knee may be passively “hyperextended”:

____ a. True
____ b. False
CONFIDENTIAL.
8. Which of the following are part of the 12. Which of the following would be external
quadriceps group of muscles? rotators of the knee?
____ a. Biceps femoris ____ a. Biceps femoris
____ b. Rectus femoris ____ b. Popliteus
____ c. Semi-membranosus ____ c. Sartorius
____ d. Semi-tendinosus ____ d. Semi-membranosus
____ e. Vastus lateralis ____ e. Semi-tendinosus
13. During the screw-home mechanism, the tibia
9. In internal rotation of the knee, which
and femur rotate on each other about:
of the following would occur?
____ a. 10 degrees
____ a. Lateral femoral condyle
____ b. 20 degrees
moves posteriorly
____ c. 30 degrees
____ b. Lateral femoral condyle
moves anteriorly ____ d. 40 degrees
____ c. Medial femoral condyle ____ e. 50 degrees

moves posteriorly
14. Which of the following anatomical features
____ d. Medial femoral condyle
of the knee are responsible for the screw-
moves anteriorly
home mechanism?
____ a. Femoral triangle
10. Range of motion for internal rotation
of the knee is about: ____ b. Femoral condyle length and shape
____ a. 10 degrees ____ c. Ligamentous tension
____ b. 20 degrees ____ d. Quadriceps mechanism
____ c. 30 degrees ____ e. Tibial plateau profile
____ d. 40 degrees
15. In a closed kinematic chain, the foot
____ e. 50 degrees
is on the ground:
____ a. True
11. Range of motion for external rotation of the
knee is about: ____ b. False
____ a. 10 degrees
____ b. 20 degrees
____ c. 30 degrees
____ d. 40 degrees
____ e. 50 degrees
following page.
CONFIDENTIAL.
Section 1 Section 2
Question Section
1. e 1
2. c 1
3. e 1 If you answered all questions correctly, turn
4. a, c, d 1 to the summary review questions on page 65.
5. b, e 1
If you answered 13 or more questions correctly,
6. c 1 complete each learning section you circled.
7. a 1
If you answered less than 13 questions
8. b, e 1
correctly, complete the entire unit.
9. a, d 2
10. c 2
11. d 2
12. a, c 2
13 b 2
14 b, c, e 2
15. a 2
CONFIDENTIAL.
Introduction
The motion of the knee appears to be that
of a hinge. It is actually a complex combination
of motion, such as gliding, rolling, and rotating.
That motion can be broken down into
components, each the result of different
muscles, acting on different parts of the joint.
To study the motion of the knee, that is what
we will look at – each component motion
and what causes it.
Kinematics is a study of motion. In the knee, it

is a complex series of motions in three planes:
• Flexion/extension - sagittal plane
• Axial rotation - transverse plane
• Abduction/adduction -
coronal (frontal) plane
Together, these individual motions provide

a composite movement that locks the knee
for stability and releases it for a wide range
of activities.
Knee kinematics provide the foundation upon

which biomechanical engineers have built an
ever-improving answer to the problems of
knee pathology.
CONFIDENTIAL.
1 Flexion/Extension
FLEXION
The Mechanics.
Flexion at the knee occurs when the lower leg Hinge
moves closer to the thigh; extension is simply
the return of the leg to the anatomic position Center
of Rotation
(Fig. 17). Flexion involves three motions:
• Rotating
• Rolling
• Gliding (sliding)
Extension
As the knee begins to flex, it first unlocks with

Femur rolls
about 20 degrees of rotation. Then the femoral forward and
glides backward
condyles roll back and glide (or slide) forward on tibia
(anteriorly) (Fig. 18).
Knee
Centers
of Rotation
Flexion
Extension
Flexion
Femur rolls
backward and
glides forward
on tibia
Fig. 17 - Flexion/extension.
Fig. 18 - Movements in flexion/extension.
CONFIDENTIAL.
Rolling. Range of Motion (ROM).
When a true hinge flexes, it moves (rotates) The range of motion in flexion is limited by
around a fixed axis, as shown in Figure 18 - the calf coming in contact with the thigh. In
Hinge. When the knee flexes, its axis of rotation flexion/extension, the knee has a normal range
is continually changing. In other words, the knee of motion from 0 to about 140 degrees. ROM is
has a multicentric rotation around its transverse less when the hip joint is extended because the
axis. As you can see in Figure 18 - Knee, those quadriceps muscles and the patellar tendons
axes follow a “J-shaped” curve. As a result, the tighten up sooner. When the hip joint is flexed,
femoral condyles roll back on the tibial plateaus the quadriceps muscles loosen up and ROM
as the knee flexes. increases somewhat. If the heel is forcibly
moved toward the buttock, ROM is even
GIiding (sliding).
more (up to about 160 degrees).
In flexion, as the femur rolls back on the tibia,
the femoral condyle glides anteriorly across Normal walking requires about 70 degrees
the tibial plateau (Fig. 18 - Flexion). If it didn’t of flexion. Going down stairs requires about 90
glide forward, the femur would impinge on the degrees of flexion and going up requires a little
posterior lip of the tibial plateau; then, the femur less. Sitting and rising from a sitting position
would roll off the back of the tibial plateau requires between 90 and 110 degrees.
(In extension, the femur glides backward
[posteriorly] as it rolls forward).
The geometry of the femoral condyles and tibial

plateaus allows a wide range of motion without
weakening the bone structure; it provides for
optimum distribution of stress.
CONFIDENTIAL.
The Muscles. For the most part, the hamstring muscles
Because flexors pull the calf toward the thigh, are “two joint” muscles. They arise from the
they cross the posterior aspect of the knee joint, tuberosity of the ischium (pelvis), except for a
as shown in Figure 19. The major flexors of the portion of the biceps that arises from the femoral
knee are the hamstring muscles, shown in shaft. The biceps femoris crosses the posterior
Figure 19, which include the: aspect of the knee on the lateral side, inserting
• Biceps femoris on the lateral condyle of the tibia. The semi-
• Semi-membranosus membranosus and semi-tendinosus both attach
• Semi-tendinosus to the medial surface of the medial condyle of the

tibia (Table 1 lists both the major and minor
flexors of the knee).
Flexors Extensors
Semi-tendinosus Vastus
Vastus Intermedus
Lateralis (underneath)
Biceps
Femoris
Rectus
Femoris
Semi-membranous
Vastus
Medialis
Posterior Anterior
Fig. 19 - Major flexors and extensors of the knee.
CONFIDENTIAL.
Major Flexors EXTENSION
Hamstring muscles
The Mechanics.
• Biceps femoris
Extension of the knee is really the reverse
• Semi-membranous
• Semi-tendinosus
of flexion, bringing the thigh back to the
anatomical position. The thigh may also be
passively moved further to the posterior, a
Major Extensors
movement some refer to as “hyperextension”
Quadriceps muscles
• Rectus femoris
of the knee. As the knee is extended, the motion
• Vastus medialis is much like that of flexion: it rolls forward and

• Vastus intermedius glides back. However, components of the knee
• Vastus lateralis joint other than the femur and tibia are
important in extension.
Minor Flexors
When the knee is flexed 90 degrees or more,
• Gastrocnemius
the patella “rides” between the condyles. As
• Gracilis
the knee extends toward its original position,
• Popliteus
the patella rides higher. In doing so it increases
• Sartorius
the moment arm of the quadriceps muscles,
increasing its efficiency by about 30%. If the
Table 1 - Flexors and extensors.
patella were not there, the quadriceps would
have to work harder to extend the knee.
CONFIDENTIAL.
Range of Motion. During extension, the patella is pulled up
The range of motion for extension is the same as over the femur in a groove known as the
that for flexion 0 to about 140 degrees, but in the patellofemoral groove. This motion is referred
opposite direction. The knee may be passively to as patellar tracking.. This track is at an angle
moved further from the anatomical position by of about 5 degrees to the mechanical axis of
about 5 to 10 degrees. Some individuals refer the tibia. This angle is known as the “Q” angle..
to this as “hyperextension.”
Muscles. Patella in
Extensors of the knee are located on the anterior Extension
surface of the thigh and leg. They include the:

• Rectus femoris
• Vastus medialis
• Vastus intermedius
• Vastus lateralis
Together, the extensors form the “quadriceps

Quadriceps
group” of muscles. All four quadriceps muscles Muscles
insert on the patellar tendon attached to the
superior portion of the patella, as shown in
Figure 19. The rectus femoris arises from the
pelvis and crosses two joints: hip and knee. The
vastus muscles all start from the femoral shaft.
Patellar
Tendons
The quadriceps muscles, along with the patella
and the patellar ligaments, provide what is
known as the “quadriceps mechanism” or
Patella
“extensor mechanism” shown in Figure 20. This in Flexion
quadriceps mechanism plays an important role,
as described above, in extension as part of
Fig. 20 - The quadriceps mechanism.
patellofemoral articulation.
CONFIDENTIAL.
2 Axial Rotation
Rotation is not the motion you generally think tibia pivot, so lateral and medial condyles move
of when you think of knee motion. Try it – in opposite directions. The lateral femoral
your knee does rotate. The motion is not as condyle travels a greater distance than the
pronounced as rotation of the hip, but it does medial condyle.
occur. You can intentionally rotate your knee,
and rotation may also occur “automatically” EXTERNAL/INTERNAL ROTATION
as part of the flexion/extension motion.
External Rotation–Mechanics.
Axial rotation occurs in the transverse plane. When you rotate your knee externally, the leg
Freedom to rotate axially is greater when the and foot turn outward away from the midline.
knee is flexed, and almost nonexistent when the The lateral femoral condyle moves forward on
knee is fully extended. Try it. Sit in a chair with the lateral tibial plateau while the medial condyle
your knee flexed. Then rotate your knee. Next, glides backward over the medial plateau (Fig. 21).
extend your knee until it points straight out. Now
try rotating again. During rotation, the femur and
External Internal
Rotation Rotation
Lateral Medial Lateral Medial
Left Femur Left Femur
Fig. 21 - Angle rotation.
CONFIDENTIAL.
Internal Rotation – Mechanics. Internal Rotation – Muscles.
When you rotate your knee internally, the leg and The muscles involved in internal rotation, as for
foot turn inward toward the midline. The lateral external, include some of the flexors. For internal
femoral condyle moves backward (posteriorly) rotation, the muscles include:
across the lateral tibial plateau while the medial • Semi-tendinosus
condyle moves forward. • Semi-membranosus
• Popliteus
External Rotation – ROM.
From a neutral position (toes forward), the knee • Gracilis
can rotate up to 40 degrees externally.
AUTOMATIC ROTATION
Internal Rotation – ROM.
From a neutral position, the knee can rotate Automatic rotation is a special aspect of knee
internally up to about 30 degrees. This gives rotation. It is called “automatic” because it
a full range of motion from internal through occurs by itself due to the unique anatomy
external of about 70 degrees. of the knee joint. Automatic rotation is important
because it is a critical component in balancing
External Rotation – Muscles.
the knee’s two opposing functions:
The muscles involved in rotation are some of the
• Stability in stance
same muscles causing flexion. External rotation
• Mobility in movement
results from the action of the
• Biceps femoris It is also an important aspect of:
• Sartorius • Range of motion
What is it? When the knee is extended, as in

standing, the femur and tibia are locked in tight
to provide stability.
CONFIDENTIAL.
In Flexion. Femoral Condyle Shape.
As flexion begins, the knee rotates to release The lateral condyle has a larger radius of
the femur and tibia, allowing the roll back of curvature compared to the medial condyle. It is
flexion. This is referred to as “unlocking.” The like rolling an axle with one large wheel (lateral)
bone that is free to move is the one to rotate. and one smaller wheel (medial). The axle (i.e.,
In flexion, with the foot off the ground, the the transverse axis of the tibia) pivots. In the
tibia is free to rotate. last 20 degrees of extension, this difference
in curvature, along with the pull of the
In Extension.
posterior cruciate ligament, causes
When the knee is nearing complete extension,
the “screw home” mechanism.
it automatically rotates once more to “lock”
the joint firmly in place for stance. This locking Figure 22 shows this difference in radius of
rotation is called the “screw-home” mechanism. curvature using sagittal sections of the lateral
When extension occurs, as during standing up and medial femoral condyles. Figure 23 shows
or stepping up, the tibia is fixed, i.e., stationary the curvature of the femoral condyles in
on the ground. In that case, the femur rotates a 3-dimensional view.
to screw-home.
Tibial Plateau Profile.
The range of automatic rotation is about Also, as you may recall, the lateral plateau
20 degrees during “screw-home.” Automatic has a convex profile, while the medial plateau
rotation results from three anatomical features is more concave. This allows the lateral condyle
of the knee: to glide back more readily. See Figure 22 for
• Femoral condyle shape the sagittal view and Figure 23 for the three
• Tibial plateau profile dimensional view.
• Ligamentous tension
CONFIDENTIAL.
Femoral Condyle Radius Tibial Plateau Profile Ligamentous Laxity
Medial Medial Condyle; Medial;

Concave Some Freedom
Lateral Lateral Condyle; Lateral;

Convex More Freedom
Fig. 22 - Factors affecting automatic rotation (screw-home mechanism).
CONFIDENTIAL.
Ligamentous Tension. What does it all mean? The unlocking
Finally, the amount of ligamentous tension mechanism and the screw-home mechanism
contributes to greater lateral movement. As are essential aspects of normal biomechanics
the knee flexes (Fig. 22), the collateral ligaments of the knee. They allow for movement and
relax somewhat. Because of their position, the stability for stance. Any prosthesis that does
attachment of the medial collateral ligament not attempt to match nature in that regard
moves slightly closer, providing some reduction will necessarily be less than ideal.
in tension. However, the attachments of the
lateral collateral ligament come even closer
together, providing more freedom to move.
This difference in ligamentous tension
(or relative increase in lateral ligamentous
laxity) also contributes to automatic
rotation (the screw-home mechanism). Right Femur
Convex Lateral
Tibial Condyle
Concave Medial
Tibial Condyle
Fig. 23 - 3-Dimensional view of femoral condyles

and tibial plateau.
CONFIDENTIAL.
FREEDOM OF MOVEMENT As you continue with your program, you will
learn how normal knee design minimizes stress
When the foot is off the ground, the tibia can
on the bones of the knee and allows proper knee
move quite freely. Some individuals refer to this
motion. Damage to the bony surfaces of the
freedom as an “open kinematic chain.” When the
knee, or loss of the cartilaginous portions,
foot is on the ground, the knee works with the
increases stress and causes pain. To relieve
ankle and hip for stability. Freedom of knee
the pain and restore the patient’s mobility, a
movement is limited by the positions of the ankle
replacement surface or joint must mimic the
and hip. This is sometimes referred to as a
design of the normal knee as closely as possible.
“closed kinematic chain.”
CLINICAL IMPLICATION
Knee motion is complex. While the knee joint has
less freedom than the ball and socket of the hip, Now complete the following review questions.
motion of the knee tends to be a combination of
types of motion. For example, knee flexion
includes rotation, rolling back, and gliding.
CONFIDENTIAL.
3 Summary Review
The following review questions will help you 4. The three flexor muscles are the:
check your understanding and grasp of major a. _______________________________
concepts presented in this chapter. Multiple b. _______________________________
choice and matching questions may have one c. _______________________________
or more correct responses. Be sure to write
5. The rectus femoris, vastus lateralis, vastus
out your answers to completion and “explain”
intermedius, vastus medialis, patella and
type questions.
patellar ligament form a functional unit
An answer key is provided at the end of these called the:
review questions. _________________________________
1. The axis of rotation for knee flexion is best 6. The purpose of the patella is to:
described by the word _________-centric. _________________________________
_________________________________
2. Briefly describe the three motions of the
femur on the tibia as the knee extends: 7. Describe the movement of the femoral
a. _______________________________ condyles on the tibial plateaus during
b. _______________________________ external rotation:
c. _______________________________ a. Lateral condyle ___________________
_________________________________
3. The total range of motion from full extension
b. Medial condyle ___________________
to the limits of simple active flexion is about:
_________________________________
__________________________________
8. Describe the movement of the femoral
condyles on the tibial plateaus during
internal rotation:
a. Lateral condyle ___________________
_________________________________
b. Medial condyle ___________________
_________________________________
CONFIDENTIAL.
9. In axial rotation, the range of motion is: 12. The purpose of automatic rotation is to
a. _________________ Degrees internally balance the knee’s two unique functions:
b. _________________ Degrees externally a. _______________________________
b. _______________________________
10. The major muscles involved in internal
(medial) rotation are the: 13. The three factors responsible for
a. _______________________________ automatic rotation are:
b. _______________________________ a. _______________________________
c. _______________________________ b. _______________________________
d. _______________________________ c. _______________________________
11. Two muscles that rotate the leg externally 14. Briefly describe what is meant by “open”
(laterally) are the: kinematic chain:
a. _______________________________ _________________________________
b. _______________________________ _________________________________
_________________________________

following page.
CONFIDENTIAL.
SUMMARY REVIEW ANSWER KEY 7. a. Glides anteriorly
b. Glides posteriorly
Questions with the following answers. If you 8. a. Glides posteriorly
missed any part of a question, count the entire b. Glides anteriorly
answer as incorrect. In essay type questions,
your answers should be similar to those given 9. a. 30 degrees
in the key; the wording need not be exactly the b. 40 degrees
same; but the meaning and the important points
should be the same. Section 2.
10. IN ANY ORDER:
The section numbers indicate where the
• Semi-tendinosus
“answer” information is discussed within the
• Semi-membranosus
chapter. Circle questions you have missed, then
• Gracilis
turn back to the appropriate section(s) and
• Popliteus
clarify the points missed before continuing
with the program. Also, rewrite the correct
answer for any question missed.
• Biceps femoris
Section 1. • Sartorius
1. Multi-(centric)
2. IN ANY ORDER: • Stability in stance
• Anterior rolling • Mobility in movement
• Posterior gliding
13. IN ANY ORDER:
• Automatic rotation
• Femoral condyle length and shape
3. 0 to 120 degrees to 140 degrees • Tibial plateau profile

• Ligamentous tension
4. IN ANY ORDER:
• Biceps femoris 14. In an open kinematic chain, the foot is off the
• Semi-tendinosus ground, and the tibia can move freely
• Semi-membranosus
5. Quadriceps mechanism
6. Improve the efficiency of the quadriceps

muscles (lengthen the quadriceps
moment arm)
CONFIDENTIAL.
Glossary
A/P [just read the letters]: Anteroposterior Articular cartilage: A special type of connective
(from front to back). tissue that covers the ends of bones that
move together in a joint; a special type of
Acrylic [ah KRIL ik]: Any of a number of clear,
“hyaline” cartilage.
transparent plastics made from a simple carbon
based (organic) acid (acrylic acid -C3H402). Articular surface: That portion of a bone that
is in contact with another bone to form a joint.
Alignment: Correct positioning; in knee
arthroplasty, the positioning of the femur Articulate: To form a joint with another bone.
and tibia so as to allow proper articulation
of the knee joint. Articulation: A connection or union allowing
motion between parts; smooth fitting of two
Alloy: A mixture of two or more metals complimentary parts of a joint.
which provides additional strength and
wear characteristics. Autoimmune: Arising from and directed
against the individual’s own tissues, as
Anatomic: Relating to the structure of an in autoimmune disease.
organism; often used to describe a prosthesis
which closely resembles or duplicates the Autologous [aw TOL oh gus]: Related to self;
shape and size of the normal body part. refers to tissues or chemicals taken from the
patient for use elsewhere in the patient.
Anterior: Pertaining to the front of the body. (Synonym -autogenous.)
Anterior cruciate [KROO she ate] ligament: Axial rotation: A turning about a fixed line.
A tough fibrous tissue band that connects
the anterior tibia to the posterior femur in Bicompartmental: Containing two sections
the anterior/posterior plane. or compartments.
Anteroposterior: Referring to a front-to-back Biconvex [buy KON veks]: Having upwardly
direction when viewed from a frontal position; rounded surfaces in two directions as you might
also A/P. see with an inverted bowl.
Arthritis: A general term referring Cartilaginous [car tih LAJ ehn us]: Composed
to inflammation of a joint. of or having the characteristics of the connective

tissue known as cartilage.
Arthroplasty [are throw PLAS tee]: An operation
to restore maximum integrity and function of a CoCr [read as: cobalt chrome]: An alloy
joint by surgical correction or reconstruction. containing the two metals chromium and cobalt.
CONFIDENTIAL.
Collateral ligaments: A pair of tough fibrous Femoral trochlea [TROKE lee ah]: A slight
connective tissue bands that attach the femur depression in the anterior surface of the distal
to the tibia on the lateral and medial aspects femur that serves as a continuation of the
to provide stability (See lateral collateral patello-femoral groove; for normal tracking of
ligament and medial collateral ligament). the patella as it moves superiorly in extension.
Concave [KON cave]: Curved downward Fibrocartilaginous [fibro carti LA jen us]:
or inward. Pertaining to a connective tissue largely
composed of cartilage along with a considerable
Convex [KON vex]: Curved upward or outward.
amount of connective tissue fibers.
Condyle [kahn dial]: A rounded surface

Fibula [FIB you lah]: The lateral and smaller
at the end of a bone.
bone of the lower leg.
Congenital [con JEN ih tahl]: Pertaining to

Fossa [FOS ah]: A hollow or depressed area;
conditions present or discovered at birth.
often used to identify specific depressions
in bone.
Cruciate [KROO she ate] ligaments: A pair
of tough fibrous tissue bands that connect the
Genu valgum [JEN you VAL gum]:
femur to the tibia in the anterior/posterior plane.
The Latin (medical) term for a valgus deformity;
They go from front to back and back to front,
a deformity known commonly as knock-knees
thereby, crossing one another; hence the name
when it involves the knee joint.
“cruciate” (See posterior cruciate ligament
and anterior cruciate ligament). Genu varum [JEN you var um]: The Latin
(medical) term for a varus deformity; a deformity
Distal [DIS tahl]: Situated or directed further
commonly known as bowlegs when it involves
away from the center of the body or some part
the knee joint.
of the body.
Hamstring muscles: A group of muscles on the
Facet [FAS et]: A small plane or surface on
back of the thigh: biceps femoris, semitendino-
a hard body.
sus, and semimembranosus, that flex the knee.
Fascia [FASH ee ah]: A band or sheet of

Hemiarthroplasty
fibrous tissue; usually found beneath the
[Heh mee are throw PLAS tee]: Joint surgery
skin, surrounding muscle, or serving as
or replacement surgery involving only one of the
an attachment point for some muscles.
articular surfaces in a joint.
CONFIDENTIAL.
Hinge: A freely moveable joint that allows Lateral femoral condyle: The curved
angular movement in only one plane. articulation portion of the distal femur
located on the side away from the midline.
Horns of the menisci: The endmost portions
(anterior and posterior) of the crescent-shaped Lateral collateral ligament: A tough fibrous
menisci (pads on the tibial plateau). connective tissue band that attaches the femur to
the tibia on the outside (lateral) aspect.
Hyaline [HIGH ah lihn] cartilage: A transparent
or nearly transparent connective tissue that Laxity: The condition of being loose; in the
covers the ends of bone to provide the articular ligaments of the knee it refers to the looseness of
surface; a type of cartilage from which bone those ligaments when tension is not applied.
develops during growth.
Ligament [LIG ah ment]: A tough band of white
Inferior: Situated or directed below. fibrous connective tissue that links two bones
together in a joint.
Intercondylar [in ter KON dih lar]:
Between the two condyles. Ligamentous tension: As the knee extends,
the medial and lateral collateral ligaments
Intercondylar [in ter KON dih lar] fossa:
maintain some degree of tension holding the
A depression between two condyles.
bones of the knee together. Less tension exists
on the lateral collateral ligament allowing the
Intercondylar tubercle
knee to “screw home.”
[in ter KON dih lar TOO burr kl]: A small
rounded elevation as occurs on some bones.
M/L: Mediolateral.
Interpositional arthroplasty: A type of

Mechanical axis: The axis formed by a line
arthroplasty in which some substitute material
through the center of the head of the femur, the
is placed between two bones to serve as the
center of the knee, and the center of the ankle.
articular surface.
Medial: Situated or directed toward the midline
Intracapsular: Within a capsule.
of the body or one of its parts.
Joint Capsule: A thick envelope of connective

Medial collateral ligament: A tough fibrous
tissue that surrounds a structure such as
connective tissue band that attaches the femur to
a joint or organ.
the tibia on the inside (medial) aspect.
Lateral: Situated or directed away from

Medial femoral condyle: The curved articulation
the midline of the body; to the side.
portion of the distal femur located on the side
near the midline of the body.
CONFIDENTIAL.
Mediolateral: Referring to a right-to-left Patellofemoral groove: A linear depression
or left-to-right direction when viewed from on the anterior surface of the distal femur
a frontal position. between the two condyles; it provides the
articular surface for movement of the
Meniscus [meh NISS cuss]: A crescent-shaped
posterior surface of the patella.
structure of tough fibrous cartilage which acts as
a cushion to distribute force between the femoral Polyethylene [Poly ETH ih leen]: A synthetic
condyles and the tibial plateaus (plural- menisci). material used in reconstructive surgery.
Methylmethacrylate Posterior: A term referring to the rear most

(Methil meth AK rih late]: The molecule portion of a body structure.
(monomer) that makes up bone cement.
Posterior cruciate [KROO she ate] ligament:
Moment arm: The distance (d) through which an A tough fibrous tissue band that connects
angular force acts. the posterior tibia to the anterior femur in
the anterior/posterior plane.
Multicentric: Having many centers. Refers to the
pattern of movement of the femur on the tibia. Proximal: Situated or positioned closer to the
center of the body, or closer to some reference
Patella: A seed-shaped (sesamoid)
part of the body.
bone commonly known as the “kneecap;”
it contributes to a pulley mechanism to “Q” angle: The angle formed in the natural
increase force for extension of the lower movement of the patella on the femoral groove
leg at the knee joint. during movement from the lateral to central
position; the angle formed by the attachment
Patellar ligament: A band of fibrous connective
of the quadriceps mechanism and the axis
tissue that attaches the inferior surface of the
of the tibia.
patella to the anterior tibia.
Quadriceps [KWAD ru seps] muscles:
Patellar tendon: Also called the quadriceps
A group of four muscles located anterior to
tendon, serves as an attachment of the
the femur which contract to extend the knee.
quadriceps muscles to the superior surface
of the patella. Radius of curvature: A measure of the degree of
curve on a curved surface such as the condyles
Patellar tracking: The movement of the
of the femur.
patella within the patellofemoral groove.
Range of motion: The arc, in degrees,
through which one part of a joint may move;
also called ROM.
CONFIDENTIAL.
ROM: Range of motion. Tricompartmental: Referring to three articular
surfaces of the knee: femoral, tibial, and patellar.
Rotation: Turning about an axis or center.
Unicompartmental: Referring to a single
Soft tissue release: The cutting of soft tissue,
articulation point. In the knee, it would be
allowing the appropriate distribution of stresses
one of the three articulation points, usually the
to achieve maximum range of motion.
medial condyle and plateau or lateral condyle and
plateau.
Stability: The ability to withstand forces
which may cause motion or alter motion.
Valgus: A condition in which the normal angle
between two structures decreases; in the knee
Synovial [sigh NO vee all]:
joint it causes a condition commonly known
Pertaining to the synovium.
as “knock-knees.”
Synovial membrane: A thin sheet of tissue lining
Varus: A condition in which the normal angle
the knee capsule. It provides nutrition
between two structures increases; in the knee
and some lubricating fluid to the articulating
joint it causes a condition commonly known
surfaces of the knee. Changes associated with
as “bowlegs.”
rheumatoid arthritis begin as a change in this
membrane. Also called the synovium.
Synovium [sigh NO vee uhm]: A membrane

lining joint capsules; it secretes synovial fluid
which lubricates the joint and provides nutrients
to the tissues within the joint.
Tendon: A tough fibrous connective tissue that

attaches muscle to bone.
Tibia: The leg bone; the proximal portion

contributes to the knee joint; the distal
portion contributes to the ankle joint.
Tibial plateau: One of two flattened areas at the

proximal end of the tibia; it serves as an articular
surface for the femoral condyles.
CONFIDENTIAL.

1 Introduction - To - The - Knee

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1 Introduction - To - The - Knee

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Sales Training

In Chapter 3,, you will learn about the motions

All of these basic concepts are important for you

Copyright ©2000, Zimmer Inc. All rights reserved.

The material contained herein, including text, charts,

____ b. Interpositional arthroplasty

7. In orthopaedics related to the knee, the major ____ b. Rheumatoid arthritis

8. The major indication for knee arthroplasty is:

5. c 1 If you answered 8 or more questions correctly,

For many people, any activity that requires

This Zimmer knee training program has

As you work through this program, read the

Other non-biological material, including

• Increased mobility surgeons) most immediate need is to meet the

• Compliance with government inventory. Instead, they are taking inventory on

directives (DRG’s) consignment and so don’t pay for the inventory

• Trauma symptomatically. If the knee is affected, as the

These correlate reasonably well with the types

Section 1. 8. ANY FOUR:

2. Hemiarthroplasty • Other congenital abnormalities

3. In hemiarthroplasty, one side of the

4. A hinged metal prosthesis

10. Minor damage refers to defects on the

In moderate damage, not only are the

In severe damage, the patient has

2. The “bony prominences” at the distal ____ d. Medial facet

15. Which of the following has the longer

____ b. Cruciate ligaments

19. The knee is held firmly locked

20. In two-legged stance (static) position, the

Check your answers with the key on the

You will need to know and understand the knee

As you work through this module, read the

is necessary for the knee to serve two opposing in Figure 2:

functions. When “locked in” or “screwed-home,” • Femur (distal end)

Fig. 2 - Bones of the knee.

Fig. 4 - Femoral trochlea.

Fig. 3 - Distal femur.

Fig. 6 - Distal tibia.

Posterior View Anterior View Lateral View

Fig. 7 - The patella.

• Anterior cruciate ligament

Fig. 9 - Schematic diagram of the knee capsule –

Lateral View Posterior View

Fig. 10 - Ligaments of the knee.

Collateral Ligaments. Cruciate Ligaments.

Not only are the articulating surfaces important,

Fig. 11 - Femoral articular surfaces.

Fig. 12 - Tibial articulating surfaces.

The femoral condyles do not exactly match the Patella.

Fig. 13 - Schematic of tibial articulating surfaces.

surface of the medial femoral condyle, the medial

Fig. 14 - Medial and lateral compartments.

Figure 15 shows the relative positions and the

Fig. 15 - Axes and angles.

Note: In the tibia the mechanical axis and the

The mechanical axis of the femur goes from

Prostheses, instruments, and surgical

1. With three single words, describe the a

actual movements that make up the overall

5. Which surface of the patella is its

6. The patella articulates with what specific

7. Briefly describe what a meniscus is:

b. Hinge-like motion c. Semi-membranosus

c. Rolling d. Semi-tendinosus

d. Sliding e. Vastus lateralis

b. Bicentric c. 30%

c. Multicentric d. 50%

c. Medial femoral condyle e. 50 degrees