Knee Joint Structure and Function

R. PETER WELSH,M.B., CH.B., F.R.C.S.(C)

Grave disability is often associated with The tibial plateaux provide reciprocal articular
major ligamentous disruption of the knee. Re- surfaces for the femoral condyles with the me-
construction of ligamentous support demands dial tibial plateau being slightly concave while
the close reproduction of normal anatomic the lateral facet presents a cartilage cap which is
structure or, failing this, the substitution of ap- almost slightly convex in profile and curves
propriate supportive function without further backward over the posterior margin of the tibial
compromise to the damaged joint. condyle (Fig. 1). This feature has clinical sig-
It is apparent therefore that a full appreciation nificance in 2 areas. First, as the popliteus initi-
of anatomic structure and function is essential, ates flexion by unscrewing the locked extended
if we are to be successful in our reconstructive knee, it enables withdrawal of the lateral menis-
procedures. This implies not only an under- cus to prevent its impaction in flexion. Second,
standing of gross anatomic features, but per- when anterior cruciate stability is lost and there
haps equally as important, an understanding of is no constraint to the forward glide of the tibia,
the physiologic properties and functions of it can subluxate slightly in extension forward
these supporting elements. and beneath the femoral condyle drawn forward
by the powerful contraction of the quadriceps.
This is associated with the clinical syndrome of
THE BASIC JOINT
anterolateral insufficiency or “the pivot
The knee joint is a modified hinge; the lim- shift, I * the subluxation reducing with a snap
”

ited rotation allowed when the knee is flexed or as the knee flexes causing the knee to collapse
semi-flexed is controlled in extension by medial or give way. Such subluxation produces a de-
rotation of the femur on the tibia locking the rangement of normal joint mechanics which can
limb and tightening the capsular structures. The lead to shearing of the articular surface, menis-
normal bony contours contribute in part to this cal damage and joint degeneration.
function because the curve of each femoral con- At first appearance, the patella presents a
dyle is cam-shaped when viewed in lateral pro- most erratic shape, divided as it is by a vertical
file.” As each condyle is flatter on the end and ridge into a large lateral and smaller medial sur-
highly curved at the free posterior margin, the face. The medial surface is further subdivided
net result is that the ligamentous structures are into 2 smaller areas. Contact areas change
relatively short in flexion but tight in extension. throughout the range of motion with large loads
being imposed upon very small areas of the pa-
tella at different phases of the gait and activity
Orthopaedic Surgeon, The Wellesley Hospital, Toronto, cycle.5 Each facet bears its share of the load,
Ontario, Canada, and Lecturer in Surgery, University of
Toronto. but abnormalities in articulation are extremely
Received: June 13, 1979. common, a myriad of symptoms being attrib-
0009-921X/80/0300/007500.90 0 J. B. Lippincott Co.
7
 Clinical Orthopaedics
8 Welsh and Related Research

portive role to the capsular structures, by virtue

of its tendinous prolongations which include
also an expansion along the medial surface of
the condyle beneath the free posterior border of
the medial ligament.
Medially, the capsule is greatly thickened
forming the deep capsular ligament. Deep to the
medial ligament of the knee joint, it forms a
thickening of the capsule extending from the
medial epicondyle of the femur to the medial
meniscus which it holds firmly to the femur.
Blending with the medial ligament above at its
femoral attachment, it is separated below by a
bursa. Elsewhere around the convexity of the
FIG. 1 . Profile of lateral tibial plateau is shown to
be convex in lateral view. meniscus the capsule is lax, forming the coro-
nary ligament. On the lateral side, the deep cap-
sular ligament is a less well developed thicken-
uted to deranged mechanics, ranging from frank ing in the capsule itself just anterior to the
patella dislocation and patellofemoral arthritis arcuate ligament blending above with the epi-
to the “patellalgia” of so called chondromala- condylar insertion of the popliteus. The remain-
cia, where there may in fact be no evidence of ing capsular or coronary ligament is thin and lax
major morphologic change in the articular carti- allowing the lateral meniscus great mobility.
lage itself.
LIGAMENTOUS REINFORCEMENT
THE JOINT CAPSULE
The capsule is further reinforced by 3 major
The integrity of the joint is maintained by a ligament groups. Anteriorly, fibrous expan-
vast capsular envelope reinforced judiciously sions from the quadriceps tendon and fascia
by retinaculae, tendons and ligaments. To the form the patellar retinaculae extending from the
femur the capsule remains attached posteriorly patella to the margins of the condyles of the
around the articular margins of the condyles and tibia blending intimately with the capsule and
above the intercondylar notch. On the lateral the ligamentum patella.
condyle this continuity is breached by the Over the lateral aspect a strong fascia1 rein-
popliteus tendon as it passes over the back of forcement is offered by the iliotibial tract as it
the tibia. Here the capsule forms a free reflec- makes its way to insert into Gerdy’s tubercle.
tion downward and laterally to the styloid proc- But the major ligamentous support is offered by
ess of the fibula as the arcuate ligament. The the fibular collateral ligament. Attached close
popliteus itself blends intimately with the cap- to the lateral epicondyle, it slopes downward
sule through its superficial fibers, while its and backward as a cordlike structure to insert in
major attachments are twofold: a cordlike ten- the back of the head of the fibula. It lies free
don inserted just below the condyle, and a short from the capsule and lateral meniscus being
flat tendon inserted into the posterior convexity separated from the meniscus by the tendon of
of the lateral meniscus. On the medial side, fur- popliteus.
ther posterior capsular reinforcement is offered The medial aspect of the joint takes its major
by the oblique popliteal ligament of Winslow, reinforcement from the tibial collateral or me-
an expansion of the semimembranosus tendon dial ligament, a phylogenetic analogue of the
which passes upward and backward to blend tendon of adductor magnus. Extending down-
with the popliteal surface of the femur immedi- ward from the epicondyle as a broad triangular
ately above the lateral condyle. The semimem- band, the anterior margin lies free except at its
branosus tendon, therefore, forms a vital sup- attached extremities and is separated from the
Number 147
March-April, 1980 Knee Joint Structure 9

FIG. 2. Anterior cruci-

ate ligament showing fiber
orientation.

medial meniscus and the deep capsular ligament by modification of the tibial insertion. Bartell
by a bursa, while the posterior margins of the and Marshall* noted that if one of the compo-
ligament pass backward to an insertion into the nents of medial instability required ligament
medial meniscus. The anterior portion contin- advancement, then distal and anterior advance-
ues below the joint line, separated from the tib- ment of tibial attachment did not appreciably
ial condyle by the forward extension of the ten- alter the strain from those normally experi-
don of semimembranosus and its bursa. The enced. However, if an advancement proximally
inferior medial genicular vessels and nerve also of the femoral attachment was made, resultant
intervene between the ligament and bone so that changes in the length of the anterior and poste-
the actual insertion of the collateral ligament is rior borders differed significantly from normal,
made quite distally below the knee joint where such that the abnormal strains developed lead to
it is embraced by the tendons of the pes anseri- ligament damage and changes in joint kinemat-
nus.3 This distal insertion is a very important ics.
feature for it enables the condyle of the tibia to
rotate freely beneath the upper part of the liga-
INTRA-ARTICULAR STRUCTURES
ment. In carrying out a surgical reconstruction,
it is important not to tether the tibial insertion of The cruciate ligaments and their function
the collateral ligament too proximally or too continue to be a source of considerable conten-
rigidly as with a staple, for this interferes mark- tion. Injury to these structures is common, with
edly with this vital rotational movement. In late exact reconstruction and restoration of normal
reconstruction, this becomes of paramount im- function difficult to achieve.’ These ligaments
portance; for if the line of action of the medial are unusual in that they lie within the capsule of
collateral ligament is altered appreciably it may the knee joint but not within the synovial mem-
be subjected to abnormal stresses as it passes brane. It is as though they have been herniated
through a range of flexion. This can only lead to into the synovial membrane from behind carry-
ligament stretching and clinical failure. l 6 ing forward over themselves a fold leaving the
It is essential in reconstruction, therefore, not posterior surfaces uncovered.
to alter appreciably the axis of this origin of the Connecting femur with tibia, they are named
medial condyle. There is much greater latitude from their tibial origins. The anterior cruciate
if tightening of the medial side is accomplished ligament is attached to the anterior part of the
 Clinical Orthopaedics
10 Welsh and Related Research

FIG. 3. The anterior

cruciate ligament inserts
into a broad flat area on
the back of the lateral
femoral condyle.

tibial plateau in front of the tibial spine and ex- lengthening or shortening of the ligament oc-
tends upward and backwards through the supra- curring with movement. Rather there is a tight-
condylar notch to an insertion over the back of ening of different components within the liga-
the lateral femoral condyle (Fig. 2). As the liga- ment through different phases of the movement
ment passes backward, it takes a turn on itself range and the actual overall length remains un-
through 90" so that it inserts not as a distinct altered.
cord but is splayed over a broad flattened area This feature of the anterior cruciate ligament
(Fig. 3). This is functionally of great impor- has an important clinical consequence. It ac-
tance, for it means that whatever the position of counts for the fact that the anterior cruciate liga-
the knee, be it full extension or 90" of flexion, ment is commonly tom, not always in combina-
portions of the ligament remain functional and tion with injury to the medial or lateral
under tension. Structurally the anterior cruciate complex, but as an isolated entity from rela-
ligament has been described as consisting of 2 tively inconsequential trauma. A sudden exten-
parts:'*9an anteromedial band and a larger pos- sion effort or abrupt change in direction under
terolateral part with the anteromedial portion load may exceed the yield point for that portion
tight at 90" of flexion. This is really an over- of the ligament under tension in that particular
simplification, for the ligament is not made up position of the knee. Arguments continue to
of 2 parts; it is a continuum of fibers with a rage as to the commonest site of tearing of the
cordlike origin fanning backwards to a broad anterior cruciate ligament, whether it be in the
insertion. It is correct in as much as the fibers substance or an avulsion from the bone at its
turn on themselves through approximately 90"; insertion to the femur. Careful dissection in
there is effectively in flexion a functioning an- over 60 cases has shown both viewpoints to be
teromedial portion while at full extension there correct. The most common tear is a combined
is a different line of force operative and a large lesion along the line of force of the predominant
posterolateral band is apparently defined. Thus, fiber band according to the position of the knee
the anterior cruciate offers important stabilizing at the time of injury. Thus, the line of separa-
control of the knee through all ranges of move- tion is usually oblique, taking part of the femo-
ment. This turning of the ligament on itself and ral insertion passing down through the sub-
the broad flattening of its insertion means that stance of the ligament to rupture in the
the ligament is truely isometric with no actual intercondylar notch. A pure lesion is seen only
Number 147
March-Aoril, 1980 Knee Joint Structure 11

when there is avulsion of the tibial origin, usu-

ally with a bone fragment. This lesion is unfor-
tunately relatively rare, for of all cruciate rup-
tures, this is the easiest to repair.
One final comment on the anterior cruciate
ligament relates to its blood supply. Invaginated
as it were into the joint from behind, the blood
is supplied posteriorly from the medial genic-
ular branch of the popliteal artery. Trauma
producing disruption of the cruciate ligaments
results in discontinuity of this vital supply so
that ligamentous atrophy follows such ligament
{jury. The difficulty since the days of Hey
Groves6 has been to devise a clinically viable
and vascularized graft through the knee. It is FIG. 4. The disposition of the cruciate ligaments
fatuous to believe that today we, any more than showing the attachments of the posterior cruciate lig-
Hey Groves, can provide a knee with structural ament.
stability by means of a fascial implant. Intra-
articular reconstructions are only viable when
the graft, that is, the fascial or tendinous band the ligament is injured at its tibial origin. If this
interposed along the line of the original liga- ligament is not reconstituted, the restoration of
ment, is revascularized and the graft reconsti- a useful blood supply is dubious for there are
tuted in the same way as a tendon graft in any few good substitutes in the way of tendon trans-
other site. fers available for the reconstruction of this liga-
The posterior cruciate ligament is the stoutest ment.
ligamentous structure in the knee joint. Ken-
nedy and Hawkinss have in tests confirmed its
THE MENISCI
strength to be as impressive as its bulk, some 2
times that of the anterior cruciate or tibial col- These dense fibrous semilunar structures in-
lateral ligaments. This would appear to offer terposed on the tibial condyle between tibia and
circumstantial support that this ligament has a femur bear most intimate relationship to the
vital role to play in knee stabilization. Cer- capsule and its ligaments. In affording support
tainly, it offers the most challenging of prob- to the femoral condyles, they must alter their
lems in knee ligament reconstruction when in- relationship through the range of knee flexion
stability results from its disruption. and extension both to accomodate the varying
Originating as a broad flat band from the pos- profile offered by the femoral condyle and to
terior part of the head of the tibia, it passes al- prevent being trapped between the articulating
most directly forward between the condyles surfaces.
medial to the anterior cruciate, converging to an C-shaped and triangular in cross-section,
insertion on the medial condyle of the femur they are avascular except at their attachments.
well forward in the intercondylar notch (Fig. 4). The medial meniscus is the larger with an open
Again the fibers twist slightly on themselves as curve whose horns enclose the curve of the lat-
they converge through the insertion. This liga- eral meniscus. The medial meniscus is fixed at
ment is perfectly located to remain isometri- its anterior and posterior horns by fibrous tissue
cally under tension throughout the whole range to the tibia. Its circumference is connected by
of knee movement offering vital control of the the capsule of the joint to the femur and tibia.
femur to prevent its subluxation forward on the Its capsular attachments to the tibia are lax;
tibia. The blood supply of the posterior cruciate those to the femur are strong on the medial side
from the middle genicular artery is disrupted if and form the deep capsular ligament. The lat-
 Clinical Orthopaedics
12 Welsh and Related Research

era1 meniscus is fixed to the tibia at both its the knee with the gracilis and the semitendino-
horns, and in addition, its posterior convexity is sus acting also as medial rotators of the tibia on
secured to the femur by the meniscofemoral lig- the femur when the knee is
aments which embrace the attachment of the On the lateral side, the conjoined tendon of
posterior cruciate ligament. the biceps femoris enfolds the lateral ligament
Various functions have been ascribed to the as it is inserted into the head of the fibula in
menisci, paramount among which is that of front of the styloid process before crossing the
load-bearing. The menisci offer a complemen- tibiofibular joint to encroach on the condyle of
tary contour to receive the opposing femoral the tibia. Primarily a flexor, the biceps also acts
condyle and adapt to it in various positions of as a lateral rotator of the tibia on the femur.
knee flexion and rotation. Thus, whatever the This latter function is, however, the major role
position of the knee, a reciprocal articulation is of the popliteus, which is responsible for rotat-
offered increasing the stability of the knee joint, ing the tibia on the femur to unlock the ex-
deepening the articular surfaces of the tibia1 pla- tended knee when it has screwed home in me-
teau and filling in the dead space which other- dial rotation. It is only with this.onlocking of
wise would exist at the periphery of the con- the knee that the hamstrings can flex the joint.
dyle, allowing synovium and capsule to intrude The lateral aspect of the knee is reinforced fur-
between the articular surfaces. This close affin- ther through the patellar retinaculum by the
ity with the articular surfaces also facilitates the continuing fibers of the iliotibial tract as they
dispersion of synovial fluid throughout the insert into the proximal G ’ ? .This forms an
joint. important part of the extensor mechanism of the
knee acting as a stabilizer of the knee in the ex-
tended position. Of itself, however, it cannot
SUPPORTIVE FUNCTION OF THE initiate extension for in full flexion its line of
SURROUNDING MUSCLE GROUPS action passes behind the axis of flexion.
SmillieI5 opens his book, “Injuries of the
Knee Joint,” with a chapter entitled “Impor-
DISCUSSION
tance of the Quadriceps.” While this muscle
group is vital to man, and its development has To discuss the function of each element of the
enabled him to assume an erect position, too knee joint as an isolated entity is to fail to ap-
often we think of this muscle as the only major preciate the close interrelationship of structure
stabilizer of the knee. However, other muscle and function of this whole complex.
groups of the thigh and leg, by their tendinous Flexion of the knee is a relatively simple
expansions, also effect major supportive func- movement produced by the hamstrings and lim-
tion to the knee joint. ited by compression of the soft parts of the knee
On the medial side, the semimembranosus against the thigh. Extension is initiated by the
inserts into the back of the medial condyle of quadriceps and limited by the tension develop-
the tibia with one expansion passing forward ing in the anterior cruciate ligament, the oblique
along the medial condyle beneath the medial lig- popliteal ligament, and the medial and lateral
ament of the knee, and another obliquely and ligaments acting sequentially. If the knee
backwards to the popliteal surface of the lateral moves into full extension, the anterior cruciate
femoral condyle as the oblique popliteal liga- becomes taut, terminating extension of the lat-
ment of Winslow. The tendons of sartorius, eral femoral condyle. Further extension of the
gracilis and semitendinosus insert into the upper medial condyle is made possible by rotation for-
part of the subcutaneous surface of the tibia en- ward of the lateral condyle around the radius of
folding the lower-most insertion of the medial the taut anterior cruciate ligament. The medial
collateral ligament in the pes anserinus. Each condyle is thus freed to glide backwards into its
tendon is separated from the other by a bursa. full extension, its articular surface being longer
The prime function of this group is flexion of and more curved than its lateral counterpart.
Number 147
March-April. 1980 Knee Joint Structure 13

Medial rotation of the femur on the tibia1 pla- one aspect of joint structure being more impor-
teau tightens the oblique popliteal ligament with tant than another. Rather, it is important to note
the obliquely set medial and lateral ligaments the smooth integration of bone structure, soft
being tightened simultaneously. As the 3 ele- tissue support and muscle control in contribut-
ments become taut, further rotation is limited ing to overall joint stability and function.
and the joint is said to have screwed home and Reconstruction of the injured knee demands
locks in slight hyperextension. The knee is thus the rebuilding of structures as closely as possi-
completely rigid. Interference with the ability to ble to reproduce the original anatomy.
extend fully thus compromises in some measure
the ultimate stability of the knee joint. This ter-
minal rotatory movement is a totally passive SUMMARY
event, resulting from the skew pull of the ob-
liquely set ligaments. To unlock the knee how- The knee joint is a modified hinge which
ever, lateral rotation of the femur must occur must allow limited rotation and flexion, yet pro-
initiated by the popliteus, so that the hamstrings vide complete stability and control under a great
can now flex the knee. In the flexed position a range of loading circumstances. The femoral
very small femoral surface articulates with the condyles are cam-shaped in lateral profile, the
plateaux, and relative relaxation of the collat- slight relative lengthening of the ligaments in
eral ligaments allows the rotation of the tibia flexion allowing rotation to occur on the tibia.
initiated by the hastrings. In extension, the ligaments and capsule become
The role of the cruciate ligaments has long taut as the femur screws home in internal rota-
been arg~ed.~.~.’.” Suffice it to say, the stability tion. The capsular envelope is judiciously rein-
of the knee is markedly jeopardized by the ab- forced medially and laterally by the collateral
sence of either and grossly so by the absence of ligaments whose prime function is to resist
both. However, there is not really such an entity varus and valgus stresses on the knee. Antero-
as a pure lesion of either; some capsular compo- posterior control is exerted by the cruciate liga-
nent must inevitably be involved. Such involve- ments which are key contributing structures to
ment, in fact, is often the factor determining overall joint stability, as they tighten on each
whether or not a knee can adequately compen- other to control the “screw home” mechanism
sate in normal activity. It is somewhat simplis- in full extension. The menisci are major load-
tic to relate the function of the cruciate liga- bearing structures which offer an improved con-
ments in terms of pure anteroposterior control. tour for femoral articulation, but their location
Yet, it is true that forward gliding of the tibia on between the moving joint surfaces renders them
the femur is controlled by the anterior cruciate vulnerable to trauma, especially when the knee
ligament and backward gliding controlled by is loaded in flexion and rotation. The muscle
the posterior. Both these ligaments together, groups investing the knee are important in stabi-
however, contribute immensely to medial and lizing the joint as well as controlling move-
lateral stability. If, with the knee extended, all ment. The close integration of all these ele-
structures are cut, excluding the cruciate liga- ments is vital to the smooth function of the knee
ments, the knee can be found to be remarkably joint. Damaged structures must be recon-
stable to valgus or varus stress. In addition, the structed as closely as possible to reproduce the
concerted effort of both cruciate ligaments is a original anatomy, if optimal function is to be
major factor in limiting both hyperextension restored to the injured joint.
and hyper-flexion.
The anatomy of the knee joint has been re-
REFERENCES
viewed in detail. Emphasis has been placed on
the close interrelationship of all elements of the I . Abbot, L. C., Saunders, J . B . , Bost, F. C., and Ander-
son, C . E.: Injuries to the ligaments of the knee joint, J .
joint complex in contributing to the overall sta- Bone Joint Surg. 26503. 1944.
bility of the joint. It is not merely a question of 2. Bartel, D. L . , Marshall, J . L . , Schick, R. A , . and
 Wang. J. B.: Surgical repositioning of the medical col- pital modification, J. Bone Joint Surg.
lateral ligament, J. Bone Joint Surg. 59A:107, 1977. 50A:1213, 1968.
3. Brantigan, 0. C., and Voshell, A. F.: The mechanics 10. Last, R. J.: Anatomy Regional and Applied, 4th edi-
of the ligaments and menisci of the knee, J. Bone Joint tion, London, J. and A. Churchill, Ltd., 1966.
Surg. 23:44, 1941. 11. MacIntosh, D. L.: The anterior cruciate ligament:
4. Gallie, W. E., and LeMesurier, A. B.: The repair of over-the-top repair, Presented to Annual Meeting
injuries to the posterior crucial ligament of the knee AAOS, Dallas, 1974.
joint, Ann. Surg. 85592, 1927. 12. Milch, H.: Injuries to the crucial ligaments, Arch.
5. Goodfellow, I . , Hungerford, D. S., and Zindel, M.: Surg. 30305, 1935.
Functional anatomy of the patello-femoral joint, J. 13. Noyes, F. R., and Sonstegard, D. A.: Biomechanical
Bone Joint Surg. 58B:287, 1976. function of pes anserinus at the knee and effect of its
6. Hey Groves, E. W.: Operation for the repair of the cru- transplantation, J. Bone Joint Surg. 55A: 1225, 1973.
cia1 ligaments, Lancet 2:674, 1917. 14. Slocum, D. B., and Larson, R. L.: Rotatory instability
7. Hey Groves, E. W.: The crucial ligaments of the knee of the knee. Its pathogenesis and a clinical test to dem-
joint: Their function, rupture, and the operative treat- onstrate its presence, J . Bone Joint Surg.
ment of the same, Br. J. Surg. 7505, 1920. 50A:211, 1968.
8. Kennedy, J. C.. Hawkins, R. J., Willis. R. B., and 15. Smillie, 1. S.: Injuries of the Knee Joint, 4th edition,
Danylchuk, K. D.: Tension studies of human knee liga- London, E. and S. Livingston, 1970.
ments, 1. Bone Joint Surg. 58A:350. 1976. 16. Wang, C. J., Walker, P. S.. and Wolf, B.: The effect of
9. Lam, S. J. S.: Reconstruction of the anterior cruciate flexion and rotation the length patterns of the ligaments
ligament using the Jones procedure and its Guy's Hos- of the knee, J. Biomech. 6587, 1973.