MOB TCD

Anatomy of Anterior Cruciate Ligament

Professor Emeritus Moira O’Brien

FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Anatomy of Knee Joint

• The knee joint is the largest joint in

the body
• One of the most frequently injured
• Synovial condylar joint
• Knee has six degrees of freedom,
three translations and three rotations
• Flexion and extension occur
between femur and menisci
• Rolling occurs above the meniscus,
• Rotation between menisci and tibia
• Gliding below the meniscus
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Knee Joint
• The mechanism of the injury is an
important factor in determining
which structure is damaged
• Injury to the anterior cruciate
ligament occurs in both contact
and non contact sports
• Females are more at risk
particularly gymnastics, skiing,
soccer volleyball and basketball
• A rapid effusion into a joint after an
injury is a haemarthrosis and, in
75% of cases, is due to rupture of
the anterior cruciate ligament
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Close-Packed
• Stable position
• Surfaces fit together
• Ligaments taut
• Spiral twist
• Screw home articular surface
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Least-Packed

• Joint more likely to be injured

least-packed
• Capsule slackest
• Joint held in this
• Position when injured
• Knee in 20°flexion
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Articular Surfaces
• The femoral articular
surfaces are the medial
and lateral femoral ACL

condyles
• The medial condyle has
a longer articular surface
• The superior aspect of
the medial and lateral
tibial condyles
• The posterior aspect of
the patella
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Articular Surfaces
• Two condyles are separated behind
by the intercondylar notch
• Joined in front by the trochlear
surface for the patella
• Femoral condyles are eccentrically
curved
• Medial is of more constant width. It
is narrow, longer and more curved
medial
• Lateral condyle is broad and straight and diverges
slightly distally and posteriorly, wider in front than at
the back
Last, 1984
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Femoral Condyles

• The radius of the condyles' curvature is

in the saggital plane,
• Becomes smaller toward the back
• This diminishing radius produces a
series of involute midpoints (i.e. located
on a spiral)
• The resulting series of transverse axes,
permit the sliding and rolling motion in the flexing knee
• While ensuring the collateral ligaments are sufficiently lax
to permit the rotation associated with the curvature of the
medial condyle about a vertical axis
Platzer, 2004
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Intercondylar Notch

• Intercondylar notch is a
continuation of the trochlea
• Varies in shape and size
• Female knee, intercondylar
notch and ACL tend to be smaller
• The mean notch width was
13.9 +/- 2.2 mm for women and
15.9 +/- 2.5 mm for men,
average is 17 mm
• Narrow notch more likely to tear
the anterior cruciate ligament
Domzalski et al., 2010; Shelbourne et al.,1998; Griffin et al.,
2006
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Tibial Superior Articular Surface

• The medial facet, oval in shape, medial
is slightly concave from side to
side, and from before backward
• The lateral, nearly circular, is
concave from side to side
• But slightly convex from before
backward, especially at its
posterior part
• Where it is prolonged on to the
posterior surface for a short
distance
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Tibial Superior Articular Surface

• The central portions of these
facets articulate with the
condyles of the femur
• Their peripheral portions
support the menisci of the
knee-joint
• The intercondylar eminence is
between the articular facets
• Nearer the posterior than the
anterior aspect of the bone
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Tibial Superior Articular Surface

PCL
• In front and behind the
intercondylar eminence are
rough depressions for the
attachment of the anterior
and posterior cruciate
ligaments and the menisci
• The shape of the cruciate
attachments vary lateral
meniscus
ACL

anterior
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Patella
• Sesamoid bone
• Thickest articular cartilage
in body
• Smaller medial facet
• Q angle
• Controlled by vastus medialis obliquus
(VMO) and vastus lateralis obliquus
(VLO)
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Patella
• The vastus medialis wastes within
24 hours after an effusion of the
knee
• If the oblique fibers of the vastus
medialis are wasted
• The patella tends to sublux laterally
when the knee is extended
• This results in retro patellar pain
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Capsular Ligaments
• Quadriceps
• Retinacular fibres
• Patellar tendon
• Coronary ligaments
• Medial and lateral ligaments
• Posterior oblique ligament
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Infrapatellar Fat Pad (IFP)

• Posteriorly
• Covered by synovial membrane
• Forms alar folds
• Blood supply of fat is by the inferior
genicular arteries
• Also supply the lower part of the ACL from
network of synovial membrane of fat pad
• Centre of fat pad has a limited blood
supply
• Lateral arthroscopic approach to avoid
injury
Williams & Warick, 1980; Eriksson et al., 1980; Kohn et al., 1995
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Infrapatellar Fat Pad (IFP)

• ACL repair with patellar tendon may
result in fibrosis of fat pad and pain
• Delays rehabilitation
• Inflammation of IFP may be process
leading to fibrosis
Murakami et al., 1995
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Anterior and Posterior Cruciates

oblique popliteal
• Anatomically named by their ligaments

tibial attachments
• Clinically, femoral attachments
are called the origin lateral

• Cruciates are intracapsular

but extrasynovial
• Cross in the sagittal plane ACL

• Covered by synovial membrane on

anterior
anterior and on both sides which is
reflected from capsule, i.e. oblique
popliteal ligament
• Bursa between them on lateral aspect
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Anterior Cruciate Ligaments

ACL

ACL

anterior
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Cruciate Ligaments

• ACL average length 31-38 mm

• ± 10 mm width and ± 5 mm thick
Odenstein, 1985; Girgis, 1975

• PCL average length 28-38 mm

• PCL is 13 mm wide
• Cruciates have a constant length ratio
• ACL : PCl of 5:3
Girgis et al., 1975
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Anterior Cruciate Ligaments

• Three dimensional fan shaped

• Multiple non-parallel interlacing
collagenous fascicles
• Made up of multiple collagen fascicles;
surrounded by an
endotendineum
• Microspically: interlacing fibrils
(150 to 250 nm in diameter)
• Grouped into fibers (1 to 20 µm in
diameter) synovial membrane envelope
Jackson et al., 1993
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Anterior Cruciate Ligaments

• Anterior cruciate is attached
to anterior aspect of the
superior surface of the tibia
• Behind the anterior horn of
medial meniscus and in front
of the anterior horn of the
lateral meniscus lateral

• Passes upwards and laterally

to the posterior aspect of
ACL
medial surface of lateral
femoral condyle
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Tibial Attachment
• Tibial attachment is in a fossa in front
of and lateral to anterior spine Medial

• Attachment is a wide area from 11

mm in width to 17 mm in AP direction
• Some anterior fibers go forward to
level of transverse meniscal
ligament; into the interspinous area
of the tibia; forming a foot-like
PCL Posterior ACL
attachment meniscofemoral
• Larger tibial than femoral attachment
• Shape of the attachment to tibia
varies
Amis,1991
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Femoral Attachment

• ACL attached to a fossa on the

posteromedial corner of medial
aspect of lateral femoral condyle in
the intercondylar notch
• Femoral attachment of ACL is well
posterior to longitudinal axis of the
femoral shaft.
• Femoral attachment is in the form
of a segmented circle
• Anterior border is straight, posterior
border convex
Arnoczky et al 1983
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Femoral Attachment

• Attachment is actually an
interdigitation of collagen fibers
and rigid bone, through a
transitional zone of
fibrocartilage and mineralized
fibrocartilage
• Attachment lies on a line which
forms a 40°angle with the long
axis of the femur
Muller, 1982; Frazer, 1975
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ACL Bundles
• The ACL consists of a smaller ACL
anteromedial and a larger
posterolateral bundle, which twists
on itself from full flexion to
extension
• The posterolateral bundle is larger
and longest in extension and
resists hyperextension
• The taut ACL is the axis for medial
rotation of the femur, during the
locking mechanism of the knee in
extension
Hunziker et al.,1992
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Anteromedial Bundle of ACL

antero medial
• Anteromedial bundle attached to bundle

the medial aspect of the

intercondylar eminence of the
tibia
• Anteromedial fibres have the
most proximal femoral
attachment
• Anteromedial bundle is longest
and tight in flexion
• Femoral insertion of the
anteromedial bundle is the
centre of rotation of ACL
Arnoczky et al 1993
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Anteromedial Bundle
• Anteromedial bundle has an isometric
behaviour
• Tightens in flexion, while the postero
lateral bundle relaxes in flexion
• Is more prone to injury with the knee in
flexion
• Anteromedial band is primary check
against anterior translation of tibia on femur
• When anterior drawer test is performed in usual manner
with knee flexed
• Contributes to anteromedial stability
O’Brien, 1992
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Posterolateral Bundle
posterolateral

• Posterolateral is attached just lateral to

midline of the intercondylar eminence
• Fibres are most inferior on femur, most
posterior on tibia
• The bulkier posterolateral bundle is not
isometric
• ACL bundles are vertical and parallel in
anteromedial
extension
• Posterolateral bundle is tight in extension
• Both bundles of ACL are horizontal at 90°flexion
Arnoczky, 1983
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Posterolateral Bundle
• Oblique position of the
posterolateral bundle
provides more rotational
control than is provided by
the anteromedial bundle,
which is in a more axial
position
• Hyperextension and internal
rotation place the
posterolateral bundle at
greater risk for injury
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Posterolateral Bundle
• It limits anterior translation,
hyperextension, and rotation
during flexion
• Femoral insertion site of the
postero lateral bundle moves
anteriorly
• Both bundles are crossed
• Posterolateral bundle loosens
in flexion
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Anterior Cruciate Ligaments

• Tibial attachment is in antero-

posterior axis of tibia
• Femoral attachment is in
longitudinal axis of femur
• Forms 40°with its long axis
• 90°twist of fibres from
• Extension to flexion
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ACL in Extension and 45°

O’Brien, 1992
 Anterior Cruciate Ligaments
• The anterior cruciates limit extension
and prevent hyperextension
• The anterior cruciate ligament is most
at risk during forced external rotation
of the femur on a fixed tibia with the
knee in full extension
Stanish et al., 1996

• During isometric quadriceps

contraction
• ACL strain at 30°of knee flexion is significantly higher
than at 90°
• Tension in ACL is least at 40°to 50°of knee flexion
Hunziker et al., 1992; Covey, 2001
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Anterior and Posterior Cruciate

• ACL
• Provides 86% of restraint to
anterior displacement
• PCL
• Provides 94% of restraint to
posterior displacement
• Hyperextension of the knee
develops much higher forces in
ACL than in the PCL
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Posterior Cruciate
• PCL is the strongest ligament of
knee
• It tends to be shorter
• More vertical
• Less oblique
• Twice as strong as ACL
• Closely applied to the centre of
rotation of knee
• It is the principle stabiliser
Hunziker et al., 1992
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Attachment of the PCL

• The tibial attachment of the
PCL was on the sloping
posterior portion of the tibial
intercondylar area
• Extended 11.5-17.3 mm
distal to the tibial plateau
• Anterior to tibial articular
margin
• Blends with periosteum and
capsule
Javadpour & O’ Brien, 1992
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Posterior Cruciate
• Anatomically the fibres pass
anteriorly, medially and
proximally
• It is attached on the antero-
inferior part of the lateral
surface of the medial femoral
condyle
• The area for the PCL is larger
than the ACL
• It expands, more on the apex
of the intercondylar notch than
on the inner wall
Frazer 1965; Hunziker et al.,1992
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Cruciates Microscopic
• Collagen fibrils 150-200 µm in
diameter
• Fibres 1-20 µm in diameter
• A subfascicular unit from100-250
µm
• 3 to 20 subfascicular units form
collagen fasciculus, 250 µm to
several millimetres
Hunziker et al.,1992
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Blood Supply of
Anterior Cruciate Ligaments
• Middle genicular enters upper third
and is the major blood supply via
synovium
• Inferior medial genicular and
Inferior lateral genicular arteries
supply via infrapatellar fat pad
• Bony attachments do not provide a
significant source of blood to distal
or proximal ligaments
Arnoczky 1987
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Blood Supply of Cruciates

 Blood Supply of
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Posteriro Cruciate Ligaments (PCL)

• PCL is supplied by four branches
• Distributed fairly evenly over its course
• Main is middle genicular artery enters
upper third of PCL
• Synovium surrounding PCL also
supplies PCL
• Contributions inferior medial, inferior lateral genicular
arteries via infrapatellar fat pad
• Periligamentous and intra-ligamentous plexus
• Sub cortical vascular network at bony attachments
• Very little from bony attachment
Sick & Koritke, 1960; Arnoczky, 1987
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Nerve Supply of Cruciates

• Branches of tibial nerve
• Middle genicular nerve
• Obturator nerve (post division)
• Branches of the tibial nerve enter
via the femoral attachment of
each ligament
• Nerve fibres are found with the
vessels in the intravascular
spaces
• Mechanoreceptors
• Proprioceptive action
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Nerve Supply of IFP

• Posterior articular branch of
tibial nerve
• Fat pad
• Supplies cruciates
• Synovial lining of cruciates
• Mechanoreceptors and pain
sensitive
Kennedy et al., Freeman & Wyke, 1967
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Mechanoreceptors
• Three types, found near the femoral
attachment
• Around periphery
• Superficially, but well below the
synovial lining
• Where maximum bending occurs
• Ruffini endings, paccinian corpuscles
• Ones resemble golgi tendon organs, running parallel to
the long axis of the ligament
• Proprioceptive function
• Posterior division of obturator nerve
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Sensory Reflex
• Sensory information from the ACL
assists in providing dynamic
stability
• Strain of ACL results in reflex
contraction of the hamstrings
• Protects ACL from excessive
loading by pulling the tibia
posteriorly
• Rapid loading ACL may rupture
before it can react
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Extension Screw Home

• Contraction of the quadriceps results in
extension
• The anterior cruciate becomes taut
• And medial rotation of the femur occurs
around the taut anterior cruciate to
accommodate the longer surface of the
medial condyle
• During extension the ACL lies in a smaller anterolateral
notch in the main intercondylar notch
• It can be kinked or torn here during hyperextension,
particularly if there is violent hyperextension and internal
rotation
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Extension

• The anterior horns of the

menisci block further movement
of the femoral condyles
• The posterior portion of the
capsule and the collateral
ligaments are also tight: this is
the close-packed position of the
joint
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Flexion
• Popliteus laterally rotates the
femur to unlock the knee
• So flexion can occur
• Then the hamstrings flex the knee
• The axis around which the motion
takes place is not a fixed one, but
shifts forward during extension
and backward during flexion

popliteus
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Screw-Home in Extension
• The effect of the screw-home
is to transform the leg into a
rigid unit, sufficiently stable for
the quadriceps to relax
• Little muscular effort is then
needed to maintain the
standing posture
• The screw-home action is due
to the inability of the central
ligaments to increase in length
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Screw-Home in Extension
• The screw-home does not
occur in the absence of the
controlling ligaments
• If the anterior cruciate and
postero-lateral complex are
missing, the lateral condyle is
not drawn forwards, resulting
in a positive pivot shift test
• Which is the abnormal
displacement of the lateral
tibial condyle on the femur
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Anatomy of the Menisci

anterior
• Menisci are made of fibro
cartilage
• Wedge shaped on cross
section
• Medial is comma shaped with
the wide portion posteriorly
• Lateral is smaller, two horns
closer together round
• They are intracapsular and
intra synovial
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Anatomy of the Menisci

• Anterior to posterior
• Medial, anterior horn is
attached to the intercondylar
area in front of the ACL and
the anterior horn of the lateral
meniscus
• Posterior horn of lateral,
posterior horn of medial and
PCL
• Medial is more fixed
anterior
• Lateral more mobile
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Anatomy of the Menisci

• Medial is attached to the deep
portion of medial collateral
ligament
• Lateral is separated from lateral
ligament by the inferolateral
genicular vessels and nerve and
the popliteus
• The popliteus, is also attached to
the lateral meniscus
• Posterior horn gives origin to
meniscofemoral ligaments
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Menisco-femoral Ligaments
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Coronary Ligament
• Connects the periphery of the
menisci to the tibia
• They are the portion of the
capsule that is stressed in rotary
movements of the knee
 Medial Collateral Ligament (MCL) MOB TCD

or Tibial Collateral Ligament

• Is attached superiorly to the
medial epicondyle of the femur.
• It blends with the capsule
• Attached to the upper third of
the tibia, as far down as the
tibial tuberosity
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or Tibial Collateral Ligament

• It has a superficial and deep
portion
• The deep portion, which is
short, fuses with the capsule
and is attached to the medial
meniscus
• A bursa usually separates the
two parts
• The anterior part tightens during
the first 70–105°of flexion
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Medial Collateral Ligament (MCL)

• Medial ligament, tightens in

extension
• And at the extremes of medial and
lateral rotation
• A valgus stress will put a strain on
the ligament
• If gapping occurs when the knee
is extended, this is due to a tear of
posterior medial part of capsule
• If gapping only occurs at 15º
flexion, this is due to tear of
medial ligament
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