Anatomy and magnetic resonance imaging of the posterolateral structures of the knee

The purpose of the present study was to provide detailed information of the morphological and radiological characteristics of the posterolateral structures of the knee. Muscles and ligaments of the posterolateral part of the knee were studied by dissections of 50 adult cadaver knees and by Magnetic Resonance Imaging (MRI) before and after dissections for comparisons. Diverse morphological characteristics of the arcuate ligament were found. The fabellofibular ligament was present in 42.1% of the knees dissected, whereas the popliteofibular ligament was found in 37.5%. A ligamentous structure, which could be called the posterior tibial ligament, was found in 31.6% of the cases that originated from the lateral part of the capsule proximally and inserted distally on the mid portion of the proximal tibia. By comparing the cross sections and the dissections of the cadaver knees, the popliteus muscle, the arcuate ligament, the fibular collateral ligament, the popliteofibular ligament, and the fabellofibular ligament could be identified in MRI. Comprehensive understanding of the posterolateral anatomy of the knee and improved identification of the structures in MRI will help clinicians to make a more accurate and noninvasive diagnosis of posterolateral instability. Clin. Anat. 10:397–404, 1997. © 1997 Wiley-Liss, Inc.     

胫骨平台后外侧象限骨折手术入路的深层解剖及后外侧与后内侧比较

目的　对比膝关节后内侧与后外侧入路所需显露的深层解剖结构,分析探讨其局限性与损伤重要结构的风险。 方法　5个成人下肢尸体标本,解剖测量胫前动静脉穿过骨间膜上裂孔的位置和腓骨头对胫骨后外侧平台的遮挡面积比例;观察膝关节后外侧入路、后内侧入路需要显露的深层结构。结合解剖研究,临床应用20例,比较两种入路的优缺点。 结果　采用后外侧入路显露胫骨平台后外侧象限,主要有下列3个缺点：(1)胫前血管束向前穿过胫腓骨间膜上裂孔,三根血管纵向宽度在1 cm左右,其前穿点距离关节面和腓骨头最高点距离平均4.93 cm和3.77 cm;其上方伴行静脉,距二者的距离分别是4.41 cm和3.25 cm,影响切口的纵向显露;(2)腓骨头遮盖后外侧象限平均61.7%,阻挡向外的横向显露宽度;(3)显露后外侧关节面,需破坏部分后外侧角结构,包括腘肌肌腱复合体、韧带、关节囊等。 结论　显露孤立的胫骨平台后外侧象限骨折,采用膝关节后内侧入路,可能更为合适。     

The anterior intermeniscal ligament of the knee: an anatomic and MR study

Background  The purposes of this study were to identify the presence of the anterior intermeniscal ligament of the knee (AIL), to study its attachment patterns and relationships to other anatomic structures within the knee and to evaluate the potential association of its rupture with other pathology of the knee. Methods  Ten human cadaver knees were dissected excluding knees with surgical scars. Fifty-one MR examinations were performed in symptomatic patients. Arthroscopic observations were carried out on ten patients. Results  AIL was found in nine dissected knees with type I insertion in six cases, type II insertion in three cases. The average length was 31.2 mm (25–45 mm). The average distance between AIL and insertion of the anterior cruciate ligament was 12 mm (11–15 mm). Concerning MR study, AIL was found in 34 cases (82.9%). Four (9.75%) ruptures of the AIL were encountered. Where AIL was intact, 14 patients presented meniscal lesions (46.6%). Where AIL was ruptured, three patients presented meniscal lesions (75%). Conclusion  The present study demonstrates through anatomical and MR studies that AIL is present in more than 80% of the cases with predominant type I insertion. The association of meniscal and AIL lesions was highlighted demonstrating that AIL is not only an anatomical point of interest but also a clinical and surgical reality.     

Obtaining anatomic motion and laxity characteristics in a total knee design

BackgroundSince the introduction of the first total knee designs, a frequent design goal has been to reproduce normal knee motion. However, studies of many currently used total knee designs, have shown that this goal has not been achieved. We proposed that Guided Motion total knee designs, could achieve more anatomic motion than present standard designs.MethodsSeveral Guided Motion knees for application without cruciate ligaments were designed using a computer method where the bearing surfaces were generated by the motion required. A knee testing machine was constructed where physiological forces including compressive, shear and torque were applied during knee flexion. The neutral path of motion and the laxity about the neutral path were measured. This evaluation method was a modification of the ASTM standard Constraint Test.ResultsThe motions of the Guided Motion knees and a standard PS knee were compared with the anatomic motion of knee specimens determined in an earlier study The Guided Motion knees showed motion patterns which were closer to anatomic than the PS knee.ConclusionsThe results provided justification for carrying out further evaluations of functional conditions, using either knee simulators or computer modelling. If anatomic motions could be reproduced in vivo, it is possible that clinical outcomes could be improved.     

Laxity and contact forces of total knee designed for anatomic motion: A cadaveric study

Background

Total knee designs that attempt to reproduce more physiological knee kinematics are gaining attention given their possible improvement in functional outcomes. This study examined if a total knee designed for anatomic motion, where the soft tissue balancing was intended to replicate anatomical tibiofemoral contact forces, can more closely reproduce the laxity of the native knee.

The extensor apparatus of the knee joint and its peripheral vasti: anatomic investigation and clinical relevance

Summary Anatomic dissections of the vastus medialis m. in 115 fixed thigh specimens always demonstrated a clear separation between a long head of the muscle (VML) inserted at the base of the patella and a short head (VMO) inserted at its medial margin. The plane of separation was identified by a branch of the femoral n. in every case. In 17 instances, the localization of the nerve was superficial; in 57, it was in the areolar fascial Plane; and in 41 instances in lay deeply between the muscles. The ramification of the branch of the femoral n. traversing the plane of separation showed 4 types of variation. Dissections of the vastus lateralis m. in 42 specimens always demonstrated a separation into 2 heads: a long head inserted at the base of the patella (VLL) and a short head inserted at its lateral margin (VLO). The directions of the individual heads of the quadriceps femoris m. were angulated in relation to the long axis of the femur. The deviations were between 10° and 17±8 laterally for the vastus lateralis longus m. (VLL), between 26° and 41° laterally for the vastus lateralis obliquus m. (VLO), between 15° and 18° medially for the vastus medialis longus m. (VML), and between 46° and 52° medially for the vastus medialis obliquus m. (VMO). The results demonstrate great Variation in the distal parts of the medial and lateral anterior thigh m.

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L'appareil extenseur du genou et les muscles vastes: investigations anatomiques et conséquences cliniques

Résumé Cent quinze dissections cadavériques du m. vaste médial ont montré de façon constante une séparation nette entre une portion longue du muscle qui s'insère à la partie supérieure (VML) de la rotule et une portion courte (VMO) qui s'insère au niveau de son bord interne. Dans chaque cas le plan de séparation a pu être identifié par une branche du n. fémoral. Dans 17 cas, le nerf était superficiel, dans 57 autres cas il se trouvait dans le plan du fascia et dans 41 cas, il était situé dans la profondeur entre les faisceaux musculaires. Les ramifications de cette branche du n. fémoral présentent 4 types de variations. 42 autres dissections du muscle vaste latéral ont montré une séparation en 2 portions: une portion longue s'insérant à la partie supérieure de la rotule (VLL) et une portion courte s'insérant au niveau de son bord externe (VLO). Les directions prises par les différents faisceaux du m. quadriceps forment un angle variable par rapport à l'axe du fémur, cet angle est de 10 à 17° en dehors pour la longue portion du m. vaste latéral (VLL), de 26 à 41° en dehors pour la portion oblique du m. vaste latéral (VLO), de 15 à 18° en dedans pour la longue portion du m. vaste médial (VML) et de 46 à 52° pour la portion oblique du vaste médial (VMO). Ces résultats montrent de grandes variations entre les parties distales des m. vastes médial et latéral.

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Early or delayed reconstruction in multi-ligament knee injuries: A systematic review and meta-analysis

Background

Whether early or delayed surgical intervention in patients with multi-ligament injuries results in better outcomes, is of current and controversial debate.

Reconstruction of chronic lesions in the posterolateral corner of the knee with autologous biceps femoralis and fascia lata grafts

OBJECTIVE:

The aim of this study was to evaluate the treatment of patients with chronic lesions in the posterolateral corner of the knee with reconstruction of the fibular collateral ligament, popliteus tendon and popliteofibular ligament and with autografts of the biceps femoris and fascia lata.

METHOD:

A total of 129 patients with injuries of the posterolateral corner of the knee that lasted for more than three weeks and were associated with the lesion of at least one of the cruciate ligaments were included. All of the patients were operated on consecutively in the same hospital between March 2004 and April 2009. Clinical evaluation using the Lyshom scale and the International Knee Documentation Committee (IKDC, item 4, assessment ligament) protocol was performed in 114 patients for whom there were complete data available.

RESULTS:

There was significant improvement in the Lyshom score and improved stability according to the IKDC protocol in the pre- compared to postoperative varus stress test at 30 degrees and the posterolateral rotation test.

CONCLUSIONS:

Surgical reconstruction of the posterolateral corner of the knee with biceps femoris tendon and fascia lata autografts is effective in stabilizing the posterolateral corner of the knee.     

髋臼后柱数字解剖学研究及解剖钢板的设计*

目的通过CT断层扫描数据的三维重建模型对髋臼后柱形态特点进行解剖学测量,为术中钢板成型及髋臼后柱解剖型钢板开发提供依据。方法采集111位成人患者(男72例,女39例)骨盆CT数据,测量股骨头直径(D);并分别通过CT断层扫描的三维反求技术重建人体骨盆解剖结构模型,测量髋臼后柱钢板放置路径中髋臼后壁、近端、远端的3段近似圆弧的曲率半径(R1、R2和R3),以及反应三段圆弧相对位置关系的髋臼后壁圆弧展角;对以上数据进行统计和相关性分析。结果成人股骨头直径(D):47.4±3.7mm;其中女性为43.6±2.3mm,男性为49.5±2.5mm。R1:48.0±7.8mm;R2:67.7±13.4mm;R3:9.8±0.4mm。:51.4°±6.8°。统计分析结果显示反应髋臼后柱钢板路径中的R1、R2、R3和与股骨头直径D和性别均无相关性。R3体现出相对独立性,其尺寸变化范围不大;而R2总体上随着R1增大而增大(线性相关系数R=0.388),而髋臼后壁圆弧展角随着R1的增大而降低(线性相关系数R=0.735)。结论髋臼后柱的解剖结构存在很大的个体差异,这种差异与股骨头直径、性别无明显相关性。髋臼后壁的形态决定了髋臼近端以及远端骨盆形态。新型髋臼后柱解剖钢板的应用,能够与髋臼后柱相匹配,缩短术中钢板塑形时间。     

河北医科大学第三医院2008-2012年成人浮膝损伤的流行病学调查

目的分析2008—2012年成人浮膝损伤患者的临床特点,探讨青年患者与中老年患者性别、合并骨折及骨折类型构成的差异,为此类骨折的诊治、预防等临床研究提供参考。方法回顾性分析河北医科大学第三医院2008年1月—2012年12月间诊治的成人(≥16岁)浮膝损伤患者资料,排除陈旧骨折、病理骨折及假体周围骨折等。所有影像资料由经过培训的4名本院骨科住院医师进行整理分型,并由本院2名骨科主任医师及1名放射科主任医师进行监督检验,统计年龄、性别、骨折类型及合并骨折等数据。≤45岁患者为青年组,>45岁患者为中老年组。结果5年间共诊治成人浮膝损伤204例208侧,占成人全身骨折的0.40%(204/52225),占成人股骨骨折的3.93%(204/5196),占成人胫腓骨骨折2.49%(204/8199)。其中男173例,女31例;年龄16~85岁;青年组153例,中老年组51例。青年患者和中老年患者中均以男性为主,分别占90.20%(138/153)和68.63%(35/51),差异有统计学意义(字2=13.808,P<0.01)。浮膝损伤患者中131例合并其他部位骨折,占浮膝损伤患者的64.22%(131/204),主要为合并足部骨折37例,尺桡骨骨折33例,骨盆-髋臼骨折31例,股骨近端骨折25例,对侧股骨骨折25例等;其中青年组合并其他部位骨折95例,中老年组36例,差异无统计学意义(字2=1.202,P>0.05)。 FraserⅠ型骨折87侧,Ⅱ型骨折121侧,青年组与中老年组患者FraserⅠ型、Ⅱa型、Ⅱb型、Ⅱc型分别是70、40、16、30侧和17、12、5、18侧,两组各型骨折构成比差异并无统计学意义(字2=5.502,P>0.05);Ⅱ型骨折中Ⅱb型骨折最少(21侧),Ⅱa、Ⅱc型骨折所占比例相近,但青年患者Ⅱa型(46.51%,40/86)骨折多于Ⅱc型(34.88%,30/86)骨折,中老年患者中Ⅱc型(51.43%,18/35)骨折较Ⅱa型(34.29%,12/35)骨折更多。结论青年男性为浮膝损伤的高危人群,常合并其他部位骨折。胫骨平台较股骨髁发生骨折的风险高,且骨折风险均随着年龄的增长而增高。     

Outcome of knee injuries in general practice: 1-year follow-up

Background

Knee injuries may lead to pain and to functional limitations in the activities of daily living. Patients with knee injuries are frequently seen in general practice; however, the outcome and management in these patients is not known.

Aim

To assess the outcome and management of knee injuries at 12 months'' follow-up in general practice.

Design of study

A prospective observational cohort study with a 1-year follow-up.

Setting

Primary health care.

Method

Adult patients consulting their GP after knee injury (n = 134) participated in the cohort. A magnetic resonance imaging scan was carried out and patients were diagnosed as either no lesion or an isolated meniscal tear, an isolated collateral or cruciate ligament lesion, or a combination. Follow-up questionnaires were filled in up to 12 months'' follow-up.

Results

At 12 months'' follow-up, 34 patients reported full recovery and 67 patients reported major improvement. At baseline, 37 patients (28%) were referred to physical therapy and 17 patients (13%) were referred to secondary care. During 1 year of follow-up, another 21 referrals to physical therapy and 11 referrals to secondary care took place. The pain severity decreased the most, and the Lysholm knee score increased in the majority of patients during the first 3 months after injury. In total, 18 arthroscopies were performed in 15 patients. One patient underwent an anterior cruciate ligament reconstruction.

Conclusion

The vast majority of patients report clinically relevant recovery. There is no clear difference in outcomes between patients with meniscal tears or ligament lesions and patients without these diagnoses.     

Convergence and interaction of somatic and visceral impulsation on neurons of the ventral posterolateral thalamic nucleus

Acute experiments on anesthetized and immobilized cats using extracellular derivation of neuronal responses and field potentials demonstrated the predominant localization of somatic (radial nerve) responses in the mediocentral and of visceral (splanchnic nerve) responses in the centrolateral regions of the ventral posterolateral thalamic nucleus. Both similarities and differences were found in patterns of neuronal responses to peripheral stimuli of different types. A quite high degree of convergence of somato-visceral impulsation was found in the central part of the nucleus compared with its medial and lateral regions. Predominance of comparatively long-latency convergent neurons over short-latency was observed. The inhibitory character of somatovisceral interaction and the more effective inhibitory influence of conditioning stimulation of the radial nerve on test-response of splanchnic origin were demonstrated.Translated from Fiziologicheskii Zhurnal imeni I. M. Sechenova, Vol. 68, No. 7, pp. 976–984, July, 1982.     

Two cases of synovial haemangioma of the knee joint: Gd-enhanced image features on MRI and arthroscopic excision

Synovial haemangioma of the knee joint is a relatively rare benign condition with around 200 reported cases. We have recently encountered two cases of synovial haemangioma of the knee joint which preoperative MRI had assessed as highly suspect and which arthroscopic resection and subsequent histological examinations confirmed as synovial hemangiomas. Published studies have identified the following as characteristic MRI features of synovial haemangioma: homogenous low intensity to iso-intensity on T1 sequence; and heterogeneous high intensity with low-intensity septa or spots within the lesion on T2 sequence. However, several other intra-knee disorders mimic these characteristics. In our two cases, we found that gadolinium (Gd)-enhanced images, which have been relatively rarely discussed in the literature, were useful for making the diagnosis and for determining the extent of this condition. These images also were very helpful during arthroscopic excision of the lesion. Nonetheless, even after Gd enhancement, differentiating between malignant conditions such as synovial sarcoma and haemangioma solely from MRI findings is still difficult.     

膝关节后交叉韧带前外侧束和后内侧束止点的解剖学研究

目的 探讨国人后交叉韧带的分束情况,对前外侧束和后内侧束的止点进行观测,掌握更为详细的解剖学资料,为临床双束重建后交叉韧带提供解剖学基础。 方法 30例膝关节标本,将后交叉韧带分为前外侧束和后内侧束,对双束股骨及胫骨端止点进行标记和解剖学观测。 结果 后交叉韧带的双束股骨止点中点至股骨内髁关节软骨前缘的距离分别为(8.52±1.81)mm和(11.63±1.81)mm,至股骨髁间窝顶的垂直距离分别为(4.67±0.55)mm和(10.32±1.23)mm;胫骨止点中点至胫骨关节面的垂直距离分别为(8.43±1.21)mm和(14.52±2.31)mm,至胫骨内侧软骨边缘的距离分别为(47.44±6.23)mm和(45.95±6.32)mm。双束股骨附丽区面积分别为(107.12±15.25)mm²和(65.35±10.27)mm²;胫骨附丽区面积分别为(50.07±11.33)mm²和(51.08±10.22)mm²。 结论 揭示了后交叉韧带双束止点的解剖学特点,为临床应用提供解剖学基础。     

Study of the variations in length of the anterior cruciate ligament during flexion of the knee: use of a 3D model reconstructed from MRI sections

Summary The aim of this study is to suggest an anatomic study of the modifications of the length of the anterior cruciate ligament (ACL) and its bundles during flexion with the aid of a 3D computerized model of the knee in a living subject. The method of evaluation suggested is a 3D computerized reconstruction based on MRI sections, reproducing the movement of flexion of the knee from 0 to 75°. Twenty-one sections were made for each of the 13 positions of flexion. The reconstruction of Delaunay and the realignment of each position provided a 3D model which allowed monitoring of a bony point during the movement. By knowing the relative displacement of the ligamentous attachments it was possible to define the biometry of the ligament by calculating the length of the bundles of the ACL in each position and to demonstrate the variations in length during the movement. The mean length of the ligament was 3.4 mm. The anteromedial bundle was longer by 30% compared with the other two bundles. During flexion the anteromedial bundle was not much modified (this feature seems to provide a reference position for a ligamentoplasty), the posterolateral bundle became taut after 30°, and the intermediate bundle relaxed from the beginning of movement. Based on the data from the literature, this method allows an anatomic approach to the ACL, bundle by bundle, during flexion movement.

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Etude des variations de longueur du ligament croisé antérieur, lors de la flexion du genou : utilisation d'un modèle 3D reconstruit à partir de coupes IRM

Résumé Ce travail a pour but de proposer à l'aide d'un modèle informatique 3D du genou chez un sujet vivant une étude anatomique des modifications de longueur du ligament croisé antérieur (LCA) et de ses faisceaux au cours de la flexion. La méthode d'évaluation proposée est une reconstruction informatique 3D, à partir de coupes IRM, reproduisant le mouvement de flexion du genou de 0 à 75°. Vingt-et-une coupes ont été réalisées pour chacune des 13 positions de flexion. La reconstruction de Delaunay et le recalage de chaque position permettent d'obtenir un modèle 3D. Ce modèle permet le suivi d'un point osseux lors du mouvement. En connaissant le déplacement relatif des insertions ligamentaires, il est possible de préciser la biométrie du ligament en calculant la longueur des faisceaux du LCA à chaque position, de mettre en évidence les variations de longueur au cours du mouvement. La longueur moyenne du ligament était de 34 mm. Le faisceau antéro-médial était plus long de 30 % par rapport aux deux autres faisceaux. Lors de la flexion, le faisceau antéro-médial était peu modifié (cette caractéristique semblait en faire une position de référence pour une ligamentoplastie), le faisceau postéro-latéral se tendait à partir de 30°, le faisceau intermédiaire se détendait dès le début du mouvement. En retrouvant les données de la littérature, cette méthode permet une approche anatomique du LCA faisceau par faisceau lors du mouvement de flexion.

     

Study of the variations in length of the anterior cruciate ligament during flexion of the knee: use of a 3D model reconstructed from MRI sections

The aim of this study is to suggest an anatomic study of the modifications of the length of the anterior cruciate ligament (ACL) and its bundles during flexion with the aid of a 3D computerized model of the knee in a living subject. The method of evaluation suggested is a 3D computerized reconstruction based on MRI sections, reproducing the movement of flexion of the knee from 0 to 75°. Twenty-one sections were made for each of the 13 positions of flexion. The reconstruction of Delaunay and the realignment of each position provided a 3D model which allowed monitoring of a bony point during the movement. By knowing the relative displacement of the ligamentous attachments it was possible to define the biometry of the ligament by calculating the length of the bundles of the ACL in each position and to demonstrate the variations in length during the movement. The mean length of the ligament was 3.4 mm. The anteromedial bundle was longer by 30% compared with the other two bundles. During flexion the anteromedial bundle was not much modified (this feature seems to provide a reference position for a ligamentoplasty), the posterolateral bundle became taut after 30°, and the intermediate bundle relaxed from the beginning of movement. Based on the data from the literature, this method allows an anatomic approach to the ACL, bundle by bundle, during flexion movement.