Knee ligaments

1. By M. Mounes
Orthopedic Department
Ain Shams University

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

4. In this session we will In this session we will
discuss :discuss :

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

5. The knee is formed from
three bones :

- Femur (Femoral Condyle)
- Tibia (Tibial Plateau)
- Patella (Articular surface)

6. Femoral Part :
-Medial femoral condyle:
* Taller than the lateral femoral condyle
* 25 degree convergent
* It is longer by 1.7cm than the lateral
condyle in the outer circumference
* Asymmetry in length produces axial
rotation of the tibia on the femur during
flexion and extension
-Lateral Femoral condyle:
AP diameter more than the medial
condyle
10 degree convergent

7. Tibial Part :
-The medial plateau is nearly
flat or concave and has a
larger surface area than the
lateral plateau.
-The lateral plateau surface is
slightly convex.
-Both plateaus have a 10-
degree posterior inclination to
the tibial shaft in the sagittal
plane.
ConcaveConcave
ConvexConvex

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

-The interspinous area is void
of hyaline cartilage, as are the
insertion sites for the
meniscal horns and cruciates.

9. Patella:
• Largest sesamoid bone in the body
(usually 3 - 5cm in length)
• Patella tendon to patella length
usually ratio of 1:1 (+/- 20%)
• 10% of patients have complete supra-
patella membranes and 75% will
have at least one of the 3 plica's even
if only as a remnant (supra-patella,
medial patella or infra-patella)
• Ossification centre appears between 2
and 3 years of age but can be as late
as 6 years

10. Patella:
It has 2 articular facets (Medial and lateral)
But recently (7)
According to the shape of the facet it is classified to :

11. In this session we will In this session we will
discuss :discuss :

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

12. Knee Stabilizers are :Knee Stabilizers are :
-Extra-articular Extra-articular
StabilizersStabilizers
-Intra-articular Intra-articular
StabilizersStabilizers"

"

"

"

"

"

"

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

"

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

13. It is formed from three layers It is formed from three layers
(Warren Marshal):(Warren Marshal):
1- First Layer: Crural fascia investing
sartorius & gastroc + Sartorius
2- Second layer :
- Superficial MCL.
- Posterior Oblique ligament
- Semi-membranosus
3- Third Layer:
- Deep MCL
- Coronary ligament
- Medial capsule

15. -Is the primary static restraint to
valgus stress at full ext. and at 30
degree flexion.
Has two portions:
* Superficial fibers (tibial
collateral ligament)
* Deep portion (medial capsular
ligament)
-Both portions originate from the
medial femoral epicondyle.

16. -The superficial MCL has two bundles :
The anterior bundle vertically oriented fibers
inserts just posterior to the insertion of the pes
anserinus;
The posterior bundle oblique fibers insert
inferior to the tibial articular surface.
- The medial capsular ligament also has two
bundles :
The meniscofemoral
The meniscotibial portions, which are
attached to the medial meniscus through the
coronary ligaments.

19. o

"

1*
& (
"
'2&+
1(
"
!
"
"!
"
#$
The five attachments of the
semimembranosus muscle :
-Direct head to the postero
medial part of proximal tibia
(pars directa)
-Deep head deep to MCL (Pars
reflexa)
-Posterior oblique ligament
-Oplique poplitial ligament
-Expansions covering the
popliteus fascia and the leg fascia

21. Long Medial collater
-POL Attaches to
PHMM & femoral
condyle.
-Recently it is
believes to be
attached to SM and
considered as one of
its attachement
-It restraints
Anterior tibial
translation and
external rotation
through its
attachment to the
PHMM and
Semimembrenosus

22. -POL rupture with
the ACL when
tibial anterior
dislocation
together with
meniscal tear.
-POL rupture with
the ACL when
tibia external
rotation

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

24. It is formed of three layers :It is formed of three layers :
1- First layer :
Biceps femoris
Iliotibial band
2- Second layer :
Patellar retinaculum
Patello femorla ligament
3-Third layer :
LCL
Popliteus tendon
Popliteofibular ligament
Popliteomeniscal fasicle
Arcuate ligament
Fabillofibular ligament
Posterior capsule +$
/C2'2
-C &D
(
7C+
ECo
.C2
Arcuate Complex:
1]LCL
2]. Arcuate lig (Y shaped
condensation)
3]. Popliteus tendon
4]. Biceps tendon
5]. Lateral head gastroc
Popliteus Popliteus
ComplexComplex

27. 1
st
Layer Ilial Tibial Tract
Bicep Femoris Peroneal Nerve

28. Exposing Layer 3
LCL
LCL

29. Deep Lamina of Layer 3
LCL
PF lig.
PF lig.

30. 2° varus stabilizer
Superficial
Deep
(Kaplan’s fibers)
Capsuloosseous
(anterolateral sling)

31. 1° varus stabilizer
Proximal / posterior
to lateral epicondyle
Midway along fibular
head
Surrounded by the
insertion of the
Biceps muscle.

32. Stabilizer to
posterolateral rotation
1- Popliteus femoral
attachement
2- Popliteomeniscal
fascicles
3- Popliteofibular ligament
4- Popliteal aponeurosis to
lateral meniscus
P
o
p
l
i
t
e
o
f
i
b
u
l
a
r
L
i
g
a
m
e
n
t
Fabellofibular
Ligament
Popliteus
Muscle
Biceps
Tendon

33. Popliteus attachment on
Femur
2 cm from FCL
Attaches on anterior fifth
of popliteal sulcus

34. Active internal rotator (unlocking)
Active antivarus joint coaptator
Passive control of external rotation
Passive control of hyperextension

35. Originates at
musculotendinous junction
Anterior / Posterior
divisions
Static stabilizer of ER
“Arcuate ligament” in old
literature

36. Fig. 8: Popliteofibular ligament, internal-external rotation (Karin Ullrich)
PT
PT
PFL
PFL
PM
PM
LM
LCL
LCL
Internal rotation tibia:
lax
External rotation tibia:
tense
LM

37. It is formed from :
-Anteromedial capsule
- Medial retinacula
-Patelofemoral and patelotibial ligament
It is formed from :
-Anterolateral capsule
- lateral retinacula
-Iliotibial band

38. Knee Stabilizers are :Knee Stabilizers are :
-Extra-articular Extra-articular
StabilizersStabilizers
-Intra-articular Intra-articular
StabilizersStabilizers"

"

"

"

"

"

"

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

"

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

39. Anatomy :Anatomy :
Tibial origin : area approximately
11 mm X 17 mm
located in front of, and lateral
to, the medial intercondylar tubercle
Femoral insertion :
posterior part of the inner surface of the lateral
femoral condyle
Dimensions :Dimensions :
11 X33 mm) '2 /40-.H-<I%
4 44
* * /4073%
The ultimate load for the young ACL was 1,725 ± 269 N. Since
that study, the criteria for the strength of autograft, allograft,
and synthetic substitutes have been set at 1,730 N.

41. fUNCTIONS:fUNCTIONS:
- Primary restrain to the anterior tibial displacement
- Primary restrain for knee internal rotation
- Secondary restrain to valgus and varus angulation at
full extension
-Propioception to the knee position
-Screw home motion occurs around its axis
Direction of fibers :Direction of fibers :
Anteromedial taut in flexion
Posterolateral taut in extension
Named According to their insertion in the tibia
The secondary restrains to the anterior tibial
drawer are :
Medial meniscus
Collateral ligaments
Joint capsule

42. $ 1 AM taught in Flexion=1 AM taught in Extension

45. Anatomy :Anatomy :
Tibial origin :
Femoral insertion :
Dimensions :Dimensions :
The PCL averages in length between 32 and
38mm and has a cross sectional area of 31.2mm2
at its mid-substance level, which is 1.5 times that
of the anterior cruciate ligament (ACL) cross-
sectional area.
Named according to Femur

46. Direction of fibers :Direction of fibers :
The PCL consists of two functional
components referred to as the anterolateral
(AL) and the posteromedial (PM) bundles
It is the primary restraint to posterior tibial
translation This is maintained throughout
range of motion as the Anterolateral bundle is
taught in flexion while the Posteromedial
bundle is taught in extension.

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

49. They are :They are :o
Ligament of Humpheryo
Ligament of Wrisborg

50. The ligament of Humphry is The ligament of Humphry is
anterior to the PCL while the anterior to the PCL while the
ligament of Wrisborg is posterior ligament of Wrisborg is posterior
to it.to it.
Both arises from the Both arises from the
posterior horn of lateral posterior horn of lateral
meniscus and attached meniscus and attached
anterior and posterior to anterior and posterior to
the PCL attachment the PCL attachment
simultaneously.simultaneously.
Ligament of
Humphery
Ligament of
Wrisborg

51. Anterior meniscofemoral
ligament
Posterior meniscofemoral
ligament
PCL

52. PCL

53. Elasto fibrocartilaginous
Crescent shaped
Medial meniscus is a small segment of a wide circle
while lat. meniscus is a large segment of a smaller
circle
Ant. horns attached by a intermeniscal ligament

54. F is the highest vascular while A is the least
vascular.
1 is the highest vascular while 3 is the least
vascular

55. Popleteus muscle is
attached to lateral
meniscus
Semimemb. Is attached to
medial meniscus Through
the POL attachemetn to
PHMM
Anterior horn of lat
meniscus and post horn of
both menisci attached to
intercondylar eminence

56. Blood supply
From branches from
lat,middle and medial
genicular arteries
Vascular synovial tissue
from the capsule
supplies the peripheral
third of the meniscus

57. Circumferential and
radial collagen fibre
type I in 98%
Matrix: Proteoglycans
glycoproteins and
elastins

58. Load bearing
At least 50% of the compressive load of
the knee joint is transmitted through the
meniscus in extension , and approx 85%
of the load is transmitted in 90° flexion.
Medial meniscus 85% LMM 75 %
Total meniscectomy can cause a fourfold
increase in articular surface stresses.
Partial meniscectomy increases forces by
50%.
When compressive force is applied to the
knee joint, the anterior and posterior
attachments of the meniscus resist
extrusion . This converts compressive force
into hoop stress, which the circumferential
orientation of the collagen fibers is ideally
suited to withstand.

59. Load bearing
The shock absorbing capacity of
normal knees is ~ 20% higher than
in meniscectomised knees.
The ability of a system to absorb
shock has been implicated in
development of OA
It has a door stopper effect preventing
anterior translation of the tibia
This has been inferred from the
finding of type 1 and type 2
nerve endings in the ant and
post horns of the menisci
• Secondary stabilizer
• Proprioception
• Joint lubrication
•
Shock absorption
• Joint nourishment

61. The knee joint is a modified
hinge synovial joint.
It is a combination of complex
motion between rolling and
gliding, ginglymus (hinge)
and trochoid (pivot).
Hence comes the recent
name (bicondyloid joint)

62. Six degrees of freedom are described to
show the relationship of the tibia and
the femur to each other.
These are broadly divided into:
-Rotational
- Translational.
The 3 rotational degrees of freedom are :
1- Flexion-extension
2- Internal-external axial tibial rotation
3- Varus valgus (adduction-abduction).
The 3 translational degrees of freedom are:
1- Anterior-posterior tibial displacement
2- Medial-lateral tibial displacement
3- Proximal-distal (joint distraction-
compression).
Constraints to excessive degrees of motion
in these freedoms are provided by
ligamentous structures around the knee.

63. How does the knee move ?
Differs from
How can the knee move ?

64. It is does not Roll

65. It is does not Glide

66. ROLLS GLIDES

68. KINEMATIC THEORIES
1) Rolling Back of the femur
3) Helical axis
4) Envelope of motion
5) Rotation with medial pivot
2) Four-bar kinematic chain
6) Screw Home motion

69. MED LAT
Roll-back of femoral condyles
1) Rolling Back of the femur

70. Strasser, Lehrbuch der muskel, 1917
Four-bar chain is not rigid
(PCL is lax in early flexion)
Zuppinger, Die active flexion, 1904
Four-bar chain is rigid
“Interactive knee”
2) Four-bar kinematic chain

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

72. Roll-back & Four-bar
Axis of motion passes through
the intersection of the bars

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

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

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

76. If axis of fixation (blumenstate line) to
the femoral axis is 90 degree
H
y
p
e
r
e
x
t
e
n
s
io
n
b
y
5
0

d
e
g
r
e
e
s

77. If axis of fixation (blumenstate line) to
the femoral axis is 40 degree
N
o
r
m
a
l
R
a
n
g
e
O
f
m
o
t
io
n

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

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

83. F
e
m
o
r
a
l


r
o
t
a
t
i
o
n
E
x
t
e
r
n
a
l
I
n
t
e
e
r
n
a
l
0
Knee flexion – Squatting (degrees)
150125100755025
25
20
15
10
5
0
5
10
3) Rotation with medial pivot

84. MFCMFC
Does not move AP Does not move AP
LFC
Moves backward 19 mm
Freeman, JBJS-B, 2000

87. DEEP FLEXION
MEDIAL LATERAL

89. AND NO ROTATIONAL AND NO ROTATIONAL
MOVEMENT OF THE MOVEMENT OF THE MFCMFC ? ?

90. “Mobility” of the LATERAL femoral condyle is due to:
1) High mobility of lateral meniscus

91. 2) Lateral tibial plateu
convex and downsloped

92. “Stability” of the MEDIAL femoral condyle is due to:
1) Restraint of the fixed posterior horn
of medial meniscus

93. 2) Medial tibial plateu
cup-shaped & “upsloped”
(»5°)

94. MFCLFC
MCL
PCL
3) Ligament colums in constant tension on MFC

95. Flexion & rotation are combined
resulting in an oblique axis.
FLEX ROT COMBINED
4) Helical axis

96. Obliquity and posterior shift produce an helical axis.
1
2
3
4
5
7
6
M L

97. Within the envelope the knee is “free” (2 D.O.F.),
but towards its limits the joint is restrained
with rotations coupled to F/E (1 D.O.F.)
5) Envelope of motion

98. 0 20 40 60 80 100
0
1
2
SWING
PHASE
STANCE
PHASE
F
e
m
o
r
a
l

t
r
a
n
s
l
a
t
i
o
n
P
o
s
t
e
r
i
o
r
A
n
t
e
r
i
o
r
Knee flexion – Stair climbing (degrees)
Hams pull tibia back
(rollforward)
PCL restrains hams
(rollback with flexion)

99. • It is the lateral rotation of the medial tibial
plateau on femur during stance phase
(extension), and internal rotation during swing
phase (flexion).
• 3 factors leads to this mechanism:
1]. The more distal alignment of the MFC
2]. The bigger radius of curvature of the MFC
3]. The cruciates crossing in-between; around
which this rotation occur
• Its significance it that it tightens both
cruciates and locks the knee in the position of
maximal stability
6) Screw Home motion

101. +,-.
/
*
!"o$&0$
'"o&0
("o$$12345363789-968:
#.5; Valgus + External Rotation is the
commonest medial side injury,
respectively;
1]. MCL then Medial capsule
2]. ACL
3]. MM = “O'DONOGHUE UNHAPPY
TRIAD”+,/
*
!"o0&0
'"o&0
("o
<"o
="o#>
?"o>
@"o&
Varus + Internal injury of lat ligaments of
the knee;
1]. LCL then lateral capsule
2]. ACL
3]. Arcuate complex
4]. Popliteus tendon
5]. ITB
6]. Biceps femoris
7]. Common peroneal nerve,

102. /67o811 %! %)
!"o&0
'"o&0A HYPEREXTENSION mechanism:
1]. ACL
2]. PCL & posterior capsule9 1o:7oo
7'1) oo
B
!"o&0
'"o&0
• ANTERO-POSTERIOR
DISPLACEMENT: e.g. dashboard
accident:
1]. ACL or
2]. PCL

104. A knee dislocation is an injury that involves
the anterior curciate ligaments and the
posterior curciate ligaments usually in
combination with the medial collateral
ligaments or the lateral collateral ligaments
and associated soft tissue structures.
Recently knee dislocation can occur with one
curciate in association with collaterals

105. MEDIAL DISLOCATION LATERAL DISLOCATION

106. ANTERIOR DISLOCATION POSTERIOR DISLOCATION

107. KD I : One of the cruciates + one of the collaterals
KDII: Both cruciates
KDIIIL : Both cruciates + LCL but MCL is Intact
KDIIIM: Both cruciates + MCL but LCL is intact
KDVI: Both cruciates + MCL + LCL
KDV: Fracture Dislocation kneeo
o
o !"
o#$ !"$
o%$&' !
()*)+!"
(*!"
Knee fracture-dislocation (Fx-Dx)
KDV.1 Fx-Dx ACL or PCL intact
KDV.2 Fx-Dx with a bicruciate injury
KDV.3 Fx-Dx, bicruciate injury, one corner
KDV.4 Fx-Dx, all four ligaments injured
+ N = Nerve injury
+ C = Vascular injury

108. History:
1- Ask about the traumatic knee event :
•Clear pop + Non contact trauma :
- ACL - Patellar Dislocation
•Clear pop + contact trauma:
- Collateral - Fracture - Meniscal
•No clear ‘pop’ PCL
2- Ask about the ability to continue walking :
• If the pt. can continue Meniscal injury / PCL
•If pt. can not Other ligamentous injury

109. 3-Ask about Knee Swelling :
• If immediate swelling Ligamentous injury
Fracture
•If late swelling meniscal injury
4-Locking:
• Meniscal injury (Bucket hundle)
•Lose body
5-Pseudo Locking:
• Hamstring spasm
•Hge + PF disorder

110. 7- Pseudo giving way:
• Reflex inhibition of muscles due to ant. Knee
pain
6- Giving way:
• Ligamentous injury
•Patellar dislocation

111. Inspection & palpation :
-Knee swelling, bruising.
-Varus or valgus malalignment
-ROM
-Gait abnormality
- Ballottement test
-Wave test
- Quadriceps wasting
and decrease in thigh
girth

112. MCL and LCL:
leg under arm, 2 hands, 30º flexion to
relax pos capsule (careful not to rotate
knee)
• Valgus stress in flexion ........... MCL
• Valgus stress in extension …... MCL
+ POL
• Varus stress (taut in full ext) .... LCL
(normally lax in flexion)

113. Grade 1
•Mild tendernes over the ligament.
•Usually no swelling.
•When the knee is bent to 30 degrees and
force applied to the inside of the knee pain
is felt but there is no joint laxity.
Grade 2
•Significant tenderness on the lateral lig.
•Some swelling seen over the ligament.
•When the knee is stressed as for grade
1 symptoms,there is pain and laxity in the joint, although there is a
definite end point.
Grade 3
•This is a complete tear of the ligament.
•When stressing the knee there is significant joint laxity.
•The athlete may complain of having a very unstable knee.

114. ACL:
-Knee flexed at 90°
-Anterior pull of the tibia. # )
# )
Anterior drawer test :Anterior drawer test :
- At 15-30º (put patient's knee over
your knee) - most sensitive !% )
!% )
Lachman test :Lachman test :
Laxity test
Functional tests

115. KT 1000 and KT 2000KT 1000 and KT 2000

116. !)$
!)$ 1- Mcintosh test1- Mcintosh test72 )
72 )
Pivot Shift Tests:Pivot Shift Tests:')0
')0
2- Lose test2- Lose test
Knee extended, valgus strain, foot internally
rotated, if instability present, tibia is subluxed
anteriorly. Now flex knee, clunk at 30º is +ve
Normal MCLand iliotibial band and torn ACL
knee & hip flexed 45º and the other hand
thumb behind the fibula. ER and valgus the
tibia + slow extension + push the fibula
forward tibial condyle shifts or subluxes
forwards in full extension.

117. 72 )
72 ) Pivot Shift Tests:Pivot Shift Tests:<) /
<) /
4- Anterior jerk off test4- Anterior jerk off test()E
()E
3- Slocum test3- Slocum test
Patient lies on unaffected side, with unstable
knee up & flexed 10º.
Medial aspect of foot rests on table. Patient
maintains ipsilateral pelvis rotated posteriorly
30-50º. Knee pushed into flexion. Easier to do
in heavy or tense patients.
This is considered the reverse of the classic
pivot shift test as it starts from flexion to
extension.

118. *: !&
*: !& 1- Ducking test1- Ducking test(: !! ! $
(: !! ! $
2- Acceleration deceleration test (Gallop Test)2- Acceleration deceleration test (Gallop Test)<: & & %$
<: & & %$
3- Single leg jump test3- Single leg jump test

119. PCL and PLC : $
Step Off test7 #
Posterior drawer test !2 %
External rotation recurvatum test
Dial test7 #
Postero lateral drawer test=$$
Whipple Ellis test> !$ !2
Quadriceps Active testo2 $2
Reversed pivot shift test 7'
7'


PLC PLC
TESTTEST

120. Step off test :
- Knee flexed at 90°

-The medial tibial plateau normally lies
approximately 1 cm anterior to the
medial femoral condyle.
-This step-off, is usually reduced in the
PCL-deficient knee
- It can easily be felt by running the
thumb down the medial femoral
condyle toward the tibia.

121. Posterior drawer
test :
The posterior drawer was the most sensitive test
(90%) and highly specific (99%).
-The patient supine, with the hip flexed to 45°, the
knee flexed to 90°, and the foot in neutral position.
- A posterior- directed force is applied to the tibia,
assessing the position of the medial tibial plateau
relative to the medial femoral condyle.

122. Posterior drawer test :
The posterior translation is graded according to the amount of posterior subluxation of
the tibia (Noyes grading):
1-Grade I : Tibial translation between 1 and 5mm.

2-Grade II : Posterior tibial translation is between 5 and 10 mm, and the tibia is
flush with the femoral condyles.

3-Grade III : This is seen when the tibia translates greater than 10 mm posterior
to the femoral condyles.

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

124. - Patient supine position.
- Suspending the lower extremity in the extension
while grasping the great toe.
The sensitivity of this test, as reported in the
literature, ranges from 33% to 94%.
External Rotation
Recurvatum Test :

125. Dial Test :
- The patient positioned prone or supine.

- An external rotation force is applied to both
feet with the knee positioned at 30° and then
90° of flexion.
-When compared with the uninjured side, an
increase of 10° or more of external rotation at
30° of knee flexion, is suggestive of an isolated
PLC injury.
- Increased external rotation at both 30° and
90° of knee flexion suggests a combined PCL
and PLC injury .

126. Quadriceps active Test :
- The patient supine and the knee flexed to 90°.
- The examiner stabilizes the foot, and the patient is asked to slide the
foot down the table.
-Contraction of the quadriceps muscle results in an anterior shift to
the tibia in the PCL-deficient knee. A shift greater than 2 mm is
considered positive for PCL insufficiency.

127. Whipple and Ellis Test :
-The patient prone and the knee
flexed at approximately 70°.
- Grasping the lower leg with one hand
and posteriorly displacing the tibia by
the other.
- This test avoids quadriceps
contraction, Moreover, if there is an
associate damage of posterior
capsular structures, the foot moves
during this test medially or laterally

128. Reverse Pivot Shift Test :
- The patient is supine and the knee is held, initially, in 90° of flexion.
- The examiner externally rotates and extends the knee.
- When positive, an anterior shift of the tibia will occur at approximately 20° to
30° of flexion. It usually signifies injury to the PLC mainly in addition to PCL
injury.

129. ! ) Meniscal tests :
1- Mcmurray test1- Mcmurray test
2- Appley compression test2- Appley compression test
3-Jerk test3-Jerk test
4-Steinmen test.4-Steinmen test.
MOST IMPORTANT TENDER MOST IMPORTANT TENDER
JOINT LINEJOINT LINE

130. Mcmurray test:

131. Appley compression distraction
test:

133. I- Anteroposterior and Lateral views :
To evaluate for fractures and/or dislocation.

134. I- Anteroposterior and Lateral views :
Mediolateral displacement
Segond`s Fracture

135. I- Anteroposterior and Lateral views :
Avulsion of tibial spine indicating ACL avulsion

136. II- Axial radiography :
- Knee flexed 70 and X ray beam
angled superiorly.
-The location of the tibia in relation
to the femur as compared with the
contralateral normal side.
-An axial press 18kg may be used to
produce maximum posterior
translation.

137. III- Stress Radiography :
-Divided according to the type of the force applied to :

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

138. B) Instrumented Technique :
Due to lack of standardized applied
force, errors in knee flexion angle and
tibial rotation, an instrumental applied
stress force is produced.
One of the most commonly used is
Telos device.

139. IV- The kneeling view (Barlet view ):
- The patient in the kneeling position applies a direct force which subluxes the
tibia posteriorly. be calculated.

140. Normal ACL , PCL and Menisci on
MRI presents
T1
T2
MRI was found to be 99% accurate and
sensitive diagnosing the presence of ACL
and PCL injury.

141. Primary Signs:
1- Change of signal
2- Change of contour
Loss of continuity Loss of continuity
in three successive in three successive
cutscuts

142. Secondary Signs:
1- Change of signal
2- Change of contour
3- Buckling of ACL and 3- Buckling of ACL and
posterior PCL line posterior PCL line
does not intersect the does not intersect the
posterior femoral line.posterior femoral line.
4- Posterior border of
the lateral plateua in
the most lateral cut is
translated anterior to
the LFC

143. MRI classification was first published by Gross et al.
Grade I : Intraligamentous lesion : High signal intensity within the ligament.

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

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

146. o
Stallar
Classification8 oo
7666o
Example of
GIII tear*o

Discoid
Meniscus

147. 9) o:o+

, oo %oo
o %o $o
%

; o oo %o
o

*o,ooo
%ooo
Bucket Handle Tear:
-Part of the meniscus
in the intercondyler
notch
-Vertical cut in the
coronal section
-Double PCL sign in
both Coronal and
Sagital

148. < %oo=o Osteochondral Lesion + MCL

149. The role of diagnostic arthroscopy is The role of diagnostic arthroscopy is
debatable as history taking, clinical debatable as history taking, clinical
examination and MRI are sufficient for examination and MRI are sufficient for
diagnosis.diagnosis.
But other surgeons state that arthroscopy can But other surgeons state that arthroscopy can
provide further information which is useful.provide further information which is useful.
Arthroscopy is done 2 to 3 weeks after injury.Arthroscopy is done 2 to 3 weeks after injury.

151. ISOLATED ACL ISOLATED PCL:
The PCL has high potential
for spontaneus healing
If avulsion ORIF
It depends on the grade:
- GI and II conservative
treatement
- GIII usually accompanied
with PLC so usually needs
rsurgical interference for
acut PLC repair then three
weeks later PCL
reconstruction
ACL has no potentional for
spontaneus healing
If tibial avulsion ORIF
If midsubstance tear we
should do ACL
reconstruction
Preopertive physiotherapy
phase I for three wks then
ACL reconstruction

152. ISOLATED MCL: ISOLATED LCL :
1.MCL has a potentional
healing as it is broad
2.According to the grade:
- GI and GII usually
conservative using
hinged knee brace and
physiotherapy
- GIII needs open repair if
early or reconstruction if
late.
LCL has no potential for
healing as it is cord like.
If grade I usually
conservative
Grade II and III treated
usually be LCL
reconstruction

153. ACL+ COLLATERAL(S)
TORN
PCL+ COLLATERAL(S)
TORN
1.Collateral ligament heal.
2.Early ROM.
3.Delayed ACL
reconstruction.
4.If PLC injuried this require
early operative repair or
reconstruction.
Treatment should be
directed 1
st
to pcl

154. ACL+PCL
1.rare
2.good outcome
3.Intact collateral make treatment simplified.
4.Early repair of PCL after ROM then delayed
ACL reconstruction or bicurciate
reconstruction simultaneously.

159. PLC injuries
acute
chronic
Isolated
(rare)
Combined with
cruciate injury
Combined with cruciate
injury
Isolated
(rare)
repair
PLC repair +/-
augmentation
Cruciate
reconstruction
PLC
reconstruction
PLC reconstruction
Cruciate reconstruction
+
+
osteotomy if varus
malignment
+

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

162. Types of grafts:
1- Autograft:
Quadriceps tendon autograft :
- It is self available
- Having a suitable size
- Has approximately three times the cross-sectional area of
the patellar tendon.
- Long enough.
- Leaves no anterior knee pain at the graft harvest site.
That makes it an acceptable graft choice for PCL reconstruction
specially double bundle technique and inlay method .
Patellar tendon autografts Causes anterior knee pain.
Hamstrings facilitate the arthroscopic method and can be split
into two sets for the double-bundle technique.

163. 2- Allograft :
Achilis tendon allograft graft is recommended :
- The osseous portion of the graft
- Has high tensile strength.
- Size and length for easily splitting in
-double bundle reconstruction.
3- Synthetic graft
4- Allograft with Synthetic graft
augmentation.
Synthetic graft
augmentation

164. 30°, 70°, 4.5 mm telescope
Pump
Shaver
Fluoroscopy for driling
the tibial tunnel
Specific PCL tools

Equipments :

165. Distal fixation: post,
endobutton, fliptag.
Aperture fixation:
interf. screws &
wedges.
II- Fixation Sites:

166. Advantages:
Provides rigid fixation.
Improves stability &
isometry.
Decreases working length
of the graft leading to less
creep & relaxation.
Avoids graft tunnel motion
Early bone intergration
and hence early walking .
Disadvantages:
Potential risk of graft
laceration or fracture.
Provides less stiffness.
Windshield wipering effect
(A/P).
Bungee cord effect
(sup/inf).
May cause delayed
incorporation & tunnel
dilatation leading to
increased laxity.
The strength & quality of
fixation may be improved
by filling the canal or by
hybrid fixation.
Aperture fixationAperture fixationDistal fixationDistal fixation

167. III- Fixation devices:
- Screw (biodegradable or
Titanium
- Endbutton or fliptag
- Tranfix or RigidFix
- Staples

168. ACL Transtibial Method
(Arthroscopic)

169. ACL Reconstruction
Steps:
-Graft Harvesting
- Graft Preparation
-Notch Debridement
- Tibial Tunnel
-Femoral Tunnel

170. Notch Debridement

171. Tibial Footprint

172. Tibial Footprint
In the center of ACL tibial insertion

173. Tibial Tunnel

174. & Femoral Footprint
For decades, the conventional
transtibial technique has been regarded
as the gold standard for ACL
reconstruction.
Femoral Tunnel

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

176. & Femoral Footprint

177. & Femoral Footprint
A nonanatomically positioned femoral tunnel
is one of the most common causes of clinical
failure after ACL reconstruction, with 15% to
31% of athletes complaining of pain,
persistent instability, or an inability to return
to the previous level of competition

179. 1- PORTALS

180. 2- Femoral Footprint

181. 2- Femoral Footprint

182. 2- Femoral Footprint

183. 2- Femoral Footprint

184. Double Bundle
ACL

185. Double Bundle Femoral Tunnels

186. Double Bundle Femoral Tunnels

187. Double Bundle Femoral Tunnels

188. Double Bundle Femoral Tunnels

189. Double Bundle Tibial Tunnels

190. Double Bundle Tibial Tunnels

191. Double Bundle Tibial Tunnels

192. Double Bundle Tibial Tunnels

194. Is there any benefit
from Double Bundle
ACL reconstruction ?

196. ACL With
Navigation System

198. Treatment of Treatment of
PCLPCL

200. Indicatioins :
1- Partial rupture of the PCL
2- Less than 10mm of posterior tibial displacement
(i.e. Grade I, II)
3- Elongation of the PCL
Physiotherapy is very essential Physiotherapy is very essential
for conservative treatment for conservative treatment
including three phases .including three phases .

201. Objects of applying physical therapy for
patients with PCL :
-Reduce swelling and knee pain
- Strengthen the quadriceps muscle.
-To stimulate the propioceptive sense.
-Sustain the elasticity of muscles around the knee.
-Let the patient know their condition so that they
can adapt daily life.

202. The Following Physiotherapy Can
be Applied For
PCL and ACL
but with difference of the mode
either accelerated (3months) or
normal rehabilitation (6 months)

203. -Knee braces applied to all patinets
and locked between 0 to 60 degrees.
-Weight bearing is allowed only
partially up to 50% of body weight.
Stretching program for thigh and leg
muscles.
- Propioceptive training is applied at
the late 4
th
week of the injury.

204. - Quadriceps muscles to be strengthened
with increasing loads.
- Co-contraction of quadricpes and
hamstrings muscles (Closed kinetic
chain exercise).
- Propiocetpive exercise continue.
- Normal gait with full weight bearing to
be allowed.
- Knee brace is still used to support the
knee during light activities in the early
phase II.

205. - Jogging straight forward, side by side,
and backward direction.
- Performing advanced propioceptive
training.
- Return to sport activity.

206. Indications for operative treatment are :
I- Avulsion PCL injuries either femoral of tibial avulsions
II- Grade III PCL injuries with significant instabilily:
Due to the probability of occult PLC injury.
III- Combined injuries :
PCL+ ACL, PCL+ PLC, PCL+MCL
IV- Failure of conservative treatment.

207.  Reduction and fixation of the avulsed fragment via either :
- Open technique
- Arthroscopic technique
 The choice of the fixation device depends
mainly on the size of the avulsed fragment:
-Large (more than 20mm) cannulated screw
-Meddium sized (10 to 20mm) K wires
-Small sized (less than 10mm) wire sutures

208. I- Posteromedial approach :

209. II- Direct posterior approach :
Biceps
Femoris
Small
Saphenous
vein
Common
peroneal nerve
Lateral head
Gastrocnemeus
Tibial
nerve
Medial Head
gastrocnemeus
Semimembronuses
Post. Joint
Capsule

210. Sandra et al. 2007 have described an arthroscopic method
PCL avulsion repair:
- Posterior triangulation for adequate visualisation for
the avulsed PCL fragment.
- Classic anteromedial and amterolateral ports for
reduction of the fragment using tibial guide.
- Stabilization of the fragment by temporarily guide
wire through the tibial guide forming tunnel A. (The
wire has 2 holes in its distal end)
- Another two tunnels B and C are formed in the
PCL crater 2cm medial and lateral to the tunnel
A.
- Steel sutures wires are passed through tunnel B, C ,then passed through the holes in
the guidewire in tunnel A, then the guide wire is pulled.There is 4 ends for steel
sutures wires free at the anterior tibial side to be tied firmly.

211. Portals :
-The standard
anteromedial and
anterolateral portals.
- In addition to posteromdial
portal.

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

213. Tibial tunnel:
- Tibial C guide used
- Entry point just distal
and medial to tibial
tubercle.
- The guide passes medial
to the ACL to the
posterior tibia.
- The vascular structures
protected by the PCL
Elevator.

214. Femoral tunnel:
-It is helpful to leave the PCL
femoral insertion fibers
intact to outline the PCL
foot print.
- For the anterolateral bundle
it present in the anterior half
of the femoral PCL insertion 8
to 9 mm from the articular
surface.
- In double bundle technique
the posteromedial bundle lies
posterior and proximal to it.

215. Femoral Tunnel tunnel:
- Femoral guide is used.
-The femoral tunnels are
marked with cautery.
- Then probed.
- Then 2 guide wires are
passed through them and
overdrilled.

217. Passage of the graft :

218. Fixation of the graft :
-Anterolateral bundle is fixed to the femrol in 90 degree frlexion.
-The posteromedial bundle is fixed in 20-30 degree flexion.
Single Bundle
Double Bundle

219. Position of the patitent:
Incisions :
-Posterior approach.
-Postrerior.

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

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

222. Harner, et al (2000)Harner, et al (2000)
- Showed in their cadaveric study that the use
of double bundle technique reduced the
posterior laxity by 3.5mm.
Bergfeld et al (2005)
- No statistical differences between the single-bundle
and double-bundle reconstructions were found at
any angle of flexion

223. Disadvantges of the transtibial method
includes :
- Neurovascular injury.(The most seriuos)
- Patients frequently retain grade I or II laxity
(Residual laxity)
- Graft failure due to killer turn.

224. Advantages of tibial inlay method:
-Imrpoved biomechanical stability by using
larger graft.
-Less risk to neurovascular structures.
-Avoid the “Killer turn” in transtibial method

225. Disadvantages of the inlay method includes:
-Change the position of the patient
intraoperatively.
-Opening of the posterior capsule.
-Longer time of operation.
-Making additional skin incision at the popliteal
fossa.

226. Bergfeld, et al. (2001)
-A study on 6 pairs of cadaveric knees, 6 inlay method and 6 transtibial
method.
-After cyclic loading, the transtibial technique grafts became
compromised and failed, that is because" killer turn” that the graft
makes at the mouth of the transtibial tunnel.
  MacGilliravay, et al. (2006)

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

228. A- Complications from trauma :
-Associated ligamentous injury
-Associated meniscal and chondral complications.
-Associated bone injury
-Fixed posterior subluxation (FPS):
* It is a posterior displacement of the tibia more that or
equal to 3mm on anterior stress radiograph.
* Reduction of the FPS is essential before any surgical
interference as it adds more stresses on the graft and leads to
its failure.

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

230. 1- Neurovascular iatrogenic injury : (The most serious)
-In transtibial tunnel during reaming.
-Methods to avoide:
I- Use of oscillating drill.
II- Use PCL elevator as a protector
II- Use of tapered instead of square
drill.
III- Intraoperative image intensifier.
IV- Formation of posteromedial
safety incision. (best method)

231. 2- Residual laxity : (The Most common)
Methods to avoid:
-The use of strong graft
-Correct tunnel placement
-Correct graft tensioning
-Secure graft fixation.
3- Loss of knee ROM
4- Medial femoral condyle osteonecrosis
5- Residual laxity : (The Most common)

232. 6- Graft failure:
Technical considerations to avoid it:
I- Smooth well chamfered tunnel edges.
II-Anatomic positioning of PCL
reconstruction tunnels to avoid acute
angles.
III-Secure fixation.
IV- Treatment of FPS before surgery.
V- Postoperative immobilization in full
extension for 4-6 weeks.

233. 7- Residual laxity : (The Most common)
-Persistent posterior sag.
- Prominent hardware.
-BTB patellar tendon graft.
-Suprapatellar synovitis.
8- Intraoperative iatrogenic fracture.

236. ;-o"5
;-o"5
#<5%
#<5% 1- Acute Repair 1- Acute Repair
(Direct Repair)(Direct Repair)
Acute repair techniques of posterolateral corner (PLC) injuries. A, Injuries to
the critical structures of the PLC. B, A sequential acute repair of the deep
structures (popliteus complex, lateral collateral ligament, and capsule) and
superficial structures (biceps and iliotibial band).

237. 7-
7- 2- Chronic PLC2- Chronic PLCo-
o-
A- Non anatomic repair :A- Non anatomic repair :

238. o-
o- A- Non anatomic repair :A- Non anatomic repair :
Primarily sling procedures
Biceps Tenodesis
(nonanatomic)

239. o-
o- A- Non anatomic repair :A- Non anatomic repair :
Deficiency of LCL
reconstruction
with
B-PT-B
Deficiency
of LCL
figure of
eight ST

240. Two tailed reconstruction of
FCL / PFL and popliteus
tendon
Biomechanically restores
function of native ligaments9-o
9-o
B- Anatomic repair :B- Anatomic repair :

241. Femoral tunnels (8 mm)
Proximal 1/5 popliteus
sulcus (PLT)
Proximoposterior to
lateral epicondyle (FCL)
7 mm interference
screws
Tibial tunnel (10 mm)
AP from distomedial
Gerdy’s to popliteus
musculotendinous
junction
Fix with bioscrew/staple
(60°, IR)

242. Warren method :
Is older method and
resembles the
previous anatomic
mentioned technique

245. -Knee braces applied to all patinets
and locked between 0 to 60 degrees.
-Weight bearing is allowed only
partially up to 50% of body weight.
Stretching program for thigh and leg
muscles.
- Propioceptive training is applied at
the late 4
th
week of the injury.

246. - Quadriceps muscles to be strengthened
with increasing loads.
- Co-contraction of quadricpes and
hamstrings muscles (Closed kinetic
chain exercise).
- Propiocetpive exercise continue.
- Normal gait with full weight bearing to
be allowed.
- Knee brace is still used to support the
knee during light activities in the early
phase II.

247. - Jogging straight forward, side by side,
and backward direction.
- Performing advanced propioceptive
training.
- Return to sport activity.

249. Zones of the meniscusZones of the meniscus

250. Long tears (more than 2.5 cm) heal poorly.
•Tears that are known to cause locking or that can be locked
during surgery are known to have higher healing failure rates.
LengthLength
Pattern of tearPattern of tear
•Vertical tears have better healing potential.
•Oblique & horizontal tears are less likely to heal.
•Stable tears heal readily ( tears less than 1 cm, tears that can
not be displaced more than 3 mm, and partial thickness tears.

251. •Non operative treatment :Non operative treatment :
Indications :Indications :
•No history of locking, a block to extension,
•No associated ACL injury
•Partial-thickness tears
•Incomplete radial tears
Stable vertical longitudinal tears
displacement less than 3mm and the length less than 10 mm in length do not need resection

252. A- PARTIAL MENISCECTOMY
•Most meniscal tears are treated by arthroscopic partial
meniscectomy.
•The goal of partial meniscectomy is to remove only the
unstable or pathologic portion, leaving as much healthy
meniscal tissue as possible while avoiding an abrupt
transition to the remaining meniscus.
•Partial meniscectomy is indicated for:
-Radial tears not extending to the periphery.
-Oblique tears (flap or parrot beak)
-Horizontal cleavage tears
-Degenerative tears
-Irreparable vertical longitudinal tears that are more than 5
mm from the absolute periphery. (i.e. in WW zone)

253. B- MENISCAL REPAIR :
Indications for Repair :

Location : We repair all tears in the red zone and most in the gray zone
Nonmacerated , nondeformed fragments in the gray zone only.

Tear pattern : Repair is indicated for vertical longitudinal tears not
Longer than 1 cm and for radial tears that extend into the red zone.

Tissue quality : We do not repair macerated and degenerative menisci.

AGE : We routinely perform meniscal repair in patients up to the age
of 45 years.

254. Accepted techniques include :
• Open repair.
• Inside-out arthroscopic repair
• Outside-in arthroscopic repair
• All-inside repair.

255. ArrowsArrows

256. Fast FixFast Fix