NJCA
  • Users Online: 662
  • Print this page
  • Email this page
  • Email this page
  • Facebook
  • Twitter


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 159-164

Posterior Cruciate Meniscofemoral Complex Morphology – Functional and Clinical Implications


1 Additional Professor, Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
2 Associate Professor, Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission10-Aug-2020
Date of Decision25-Oct-2020
Date of Acceptance21-Nov-2020
Date of Web Publication7-Dec-2020

Correspondence Address:
Rekha Lalwani
Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_63_20

Rights and Permissions
  Abstract 


Background: The posterior cruciate meniscofemoral ligament (MFL) complex is considered an important stabilizing structure in the human knee joint. Its role in preventing tibial translation and preventing lateral meniscus injuries is increasingly being recognized. The knowledge of the anatomy of this complex, however, lags behind as compared to our knowledge and understating of its counterpart, the anterior cruciate ligament. Methods: Sixteen adult cadaveric knee joints (eight left and eight right) were utilized for this study. The posterior cruciate ligament (PCL) complex was resected out and its morphologic and morphometric assessment was done. Results: The PCL was short and stout ligamentous complex, mostly (but not always) clasped by either anterior MFLs, posterior MFL, or both. The tibial footprint was more or less circular, whereas the femoral footprint was oval and mediolaterally flattened. The PCL was constituted of two distinct fiber bundles, namely anterolateral and posteromedial. The MFLs originated from the posterior margin of the lateral meniscus just proximal to the posterior horn. The two MFLs ascend from their origin, bifurcate, and diverge to clasp the PCL. At least one MFL was observed in all specimens. Conclusion: The anatomical relationship of PCL, meniscofemoral, popliteus, and lateral meniscus suggests that they complement each other for a fine interplay and balance to execute terminal extension while simultaneously protecting the lateral meniscus. The findings of the present study contribute toward improving surgical repairs in double-bundle PCL repairs.

Keywords: Knee joint, lateral meniscus, lateral meniscus injuries, meniscofemoral ligament


How to cite this article:
Athavale SA, Kotgirwar S, Lalwani R. Posterior Cruciate Meniscofemoral Complex Morphology – Functional and Clinical Implications. Natl J Clin Anat 2020;9:159-64

How to cite this URL:
Athavale SA, Kotgirwar S, Lalwani R. Posterior Cruciate Meniscofemoral Complex Morphology – Functional and Clinical Implications. Natl J Clin Anat [serial online] 2020 [cited 2021 Jan 16];9:159-64. Available from: http://www.njca.info/text.asp?2020/9/4/159/302570




  Introduction Top


The posterior cruciate ligament (PCL) is one of the four major ligaments of the knee. It is stronger and thicker than the anterior cruciate ligament (ACL).[1] The PCL is attached to the lateral surface of the medial condyle of the femur. Two bundles, namely anterolateral and posteromedial, have been identified in PCL which are named according to their femoral attachments.[2] The anterolateral bundle is taut in flexion and the posteromedial bundle is taut in extension.[3]

Initially described as the third cruciate ligament, the meniscofemoral ligaments (MFLs) clasp the PCL and have been named the anterior MFLs (aMFLs) and posterior MFLs (pMFL). They are an integral part of PCL complex. These ligaments initially considered to be secondary restraints to the posterior tibial translation[4] are now considered to play a significant role in:

  1. Stabilizing and protecting the posterolateral tibiofemoral component of the knee
  2. Increasing the congruity of the mobile lateral meniscus and the lateral femoral condyle
  3. Assisting the lateral meniscus in reducing the tibiofemoral contact pressure.[5]


Different studies have reported different prevalences of these ligaments ranging from 71% to 100%.[6],[7],[8]

At present, our knowledge of the PCL still lags behind the ACL.[9] It is known that the success of reconstruction surgeries hinges on precise anatomic restoration. However, there is no consensus on the detailed anatomy of the PCL and the most appropriate method of PCL reconstruction. Improvements in the treatment and the rehabilitation of PCL injuries are based on continued advances in the basic sciences of the PCL.[10]

Studies have been conducted in various ethnic groups on the PCL complex, but such a study is still wanting in central India.[3],[5],[6],[7],[8],[9],[10]

The present study is undertaken for the detailed observation of the different bundles of the PCL, their footprints, and their associated ligaments for the better comprehension of the anatomy of PCL complex in central Indians to facilitate the design of the PCL reconstruction.


  Materials and Methods Top


This cross-sectional descriptive study was conducted from December 2016 to February 2018 after obtaining ethical clearance from the Institutional Human Ethics Committee of AIIMS, Bhopal. Sixteen adult apparently normal knee joints (8 left and 8 right) obtained from embalmed cadavers of the central India population were utilized for this study. All the limbs were fixed with knee joints in extended positions. The sex of the knee joints utilized could not be ascertained, as already disarticulated lower limbs available in the collection of the department of anatomy were utilized for the study.

Knee joints with any evidence of congenital or acquired knee pathology including osteoarthritis, trauma, or knee joints with evidence of surgical interventions affecting PCL complex were excluded from this study.

The knee joint was exposed from the posterior aspect; the skin over the popliteal fossa was reflected by giving a cruciate incision. The structures and boundaries of the popliteal fossa were cleaned off; also, the connective tissue and the fat were cleared off. The medial and lateral head of gastrocnemius was cut from the origin and reflected. The neuromuscular bundle in the popliteal fossa was cut and reflected. After exposing the fibrous capsule from the posterior aspect, the capsule was cut, giving a medial parasagittal incision and a horizontal incision. This was intended to preserve the PCL complex which is adhered to the fibrous capsule. The fibrous capsule was carefully reflected, separating it from the PCL complex. The MFLs were identified.

The PCL complex was resected by cutting the tibial and femoral attachments, along with the lateral menisci, to preserve the attachments of MFLs on the lateral meniscus.[11]

To document the footprints of the posterior cruciate ligament

The PCL was detached from its tibial and femoral attachments. The tibial and femoral footprint margins were circumscribed by a permanent marker. These footprints were then translated on a piece of glass plate by apposing each footprint onto the glass plate and creating a replica of the footprint on the surface of the glass plate. These were then further translated and charted on a graph paper to calculate the surface area of each footprint [Figure 1].
Figure 1: Surface area charting of posterior cruciate ligament

Click here to view


The length of PCL was measured from the most anterior point of tibial footprint to the most anterior point of femoral footprint with the help of thread and vernier caliper.[12],[13]

The synovial membrane was carefully removed. The MFLs and different fiber bundles along with their relative positions were identified under a magnifying glass. Disposition of fibers in individual fiber bundles was also noted.

Statistical analysis of the morphometric measurements for descriptive statistics was done on SPSS software.


  Results Top


The PCL was short and stout ligamentous complex, mostly (but not always) clasped by either aMFL, pMFL, or both [Figure 2]a and [Figure 2]b. Tibial footprint was more or less circular, whereas the femoral footprint was oval and mediolaterally flattened. The PCL was constituted of two distinct fiber bundles, namely anterolateral and posteromedial with respect to their attachment on the tibia. The anterolateral was cord like and posteromedial bundle fanned out superolaterally [Figure 3]a and [Figure 3]b.
Figure 2: (a) Posterior cruciate ligament complex of left along with lateral meniscus, anterior cruciate ligament and popliteus muscle, (b) Showing schematic diagram of posterior cruciate ligament complex-related structure: aMFL: Anterior meniscofemoral ligament, pMFL: Posterior meniscofemoral ligament

Click here to view
Figure 3: (a) Two distinct bundles of posterior cruciate ligament of the left knee. (b) Show schematic diagram of the posterior cruciate ligament of the left knee: AL: Anterolateral bundle, PM: Posteromedial bundl

Click here to view


The length of PCL was 30.7 ± 5.3 mm on the right side and 29 ± 7.6 mm on the left side. The difference between the two sides was statistically not significant. [Table 1] shows descriptive statistics of the morphometric assessment of PCL and its components. The difference between the two sides was statistically not significant. The tibial and femoral footprints were positively and significantly correlated with each other (Pearson’s correlation 0.576 and P < 0.05). The two bundles, anterolateral and posteromedial, were almost similar in length [Table 1] and showed slight negative correlation as regards to their length. However this was statistically not significant.
Table 1: Descriptive statistics of various parameters of posterior cruciate ligament

Click here to view


Meniscofemoral ligament

The MFLs originated from the posterior margin of lateral meniscus just proximal to the posterior horn. The two MFLs ascend from their origin, bifurcate, and diverge to clasp the PCL [Figure 4]a.
Figure 4: (a) Anterior meniscofemoral ligament and posterior meniscofemoral ligament clasping the posterior cruciate ligament, (b) showing extension of posterior horn of lateral meniscus extending further medially

Click here to view


The fibers of MFLs were aligned obliquely with respect to PCL. The fiber arrangement of aMFL and pMFL also varied with respect to each other, as they do not run parallel to each other. The origin of pMFL was very close and sometimes confluent with the origin of the popliteus muscle. Both meniscofemorals were attached to the femur at the other attachment. The aMFL was relatively more horizontal than pMFL [Figure 2]a.

[Table 2] shows the number and percentage of prevalence of MFLs in the present study.
Table 2: Number and percentage of prevalence of meniscofemoral ligament in the present study

Click here to view


The posterior end of the lateral meniscus sometimes extended further medially giving a “J” shape to the meniscus [Figure 4]b.

Few notable observations were as follows. In three cases, the pMFL was appreciably larger [Figure 5]a and [Figure 5]b and in one case, aMFL was appreciably prominent.
Figure 5: (a and b) Larger posterior meniscofemoral ligament of the right and left sides: PCL: posterior cruciate ligament

Click here to view



  Discussion Top


Posterior cruciate ligament morphology

Primarily designed to resist the posterior translation of the tibia on the femur in all positions of the knee joint, the two bundles are meant to resist this translation in different positions.[14],[15] The present study also observed similar bundles. However, in contrast to the observations by Kweon et al.[14] and LaPadre et al.,[16] the anterolateral was cord like rather than the posteromedial bundle.

The PCL length as observed in the present study is lower than that of previous studies by about 8 mm.[14],[15] This may be due to racial differences (previous studies have been conducted on the Caucasian population) or due to different landmarks used for measuring length.

Our findings of difference in cross-sectional area of tibial and femoral footprints (tibial being more than twice than femoral) corroborate with findings of studies reported by LaPrade et al.[16]

Meniscofemoral ligament

Various cadaveric and radiological studies have reported variable prevalences of MFL. The presence of at least one MFL was documented in the range of 71–100%, bilateral presence was documented in 5–50% of cases. The prevalence of pMFL was higher than aMFL, especially in radiological studies,[17],[18],[19],[20],[21] as recognition of aMFL is difficult in magnetic resonance imaging owing to its smaller size.

aMFL is generally believed to be thinner than that of pMFL. However, the present study documented one case of appreciably thick aMFL. Investigators have reported that two bundles of PCL have a significant primary role in resisting posterior tibial translation throughout the range of flexion of the knee joint.[15],[16],[17],[18],[19],[20],[21],[22]

MFLs are also considered as secondary restrain for posterior tibial translation. A study by Gupte et al.[20] has documented MFLs contribute to 28% resistance to posterior tibial translation in the intact knee and 70% in PCL-deficient knee, thereby lending evidence to the hypothesis that MFLs are secondary restraints to the posterior tibial translations.

The role of MFL in mobility of the posterior horn of the lateral meniscus has not been discussed much. The authors tend to agree with the proposition of Last[23] and Simonian et al.[24] that the fine control of exerted by MFLs and popliteus in antagonist fashion [Figure 2]a and [Figure 2]b prevents tears of the lateral meniscus.

The posterior tibial attachment of lateral meniscus is a peculiarly human feature after assumption of erect posture. Its purpose is to restrict anteroposterior movements of the lateral meniscus to reinforce the knee extension stability.[25],[26] The MFL along with the popliteus muscle has a significant role to play in fine-tuning the lateral meniscus movement.

There is an ongoing debate and recent literature is favoring the superiority of double-bundle repair.[27] The findings of the present study hence may be utilized, especially for the Indian population, as the studies till date are lacking in Indian data.


  Conclusion Top


PCL complex consisted of PCL and two MFLs clasping it. PCL is constituted of two distinct fiber bundles, namely anterolateral and posteromedial. At least one MFLs is present in all specimens studied. The tibial and femoral footprints differ in morphology and morphometry.

The anatomical relationship of PCL, meniscofemoral, popliteus, and lateral meniscus suggests that they complement each other for affine interplay and balance to execute terminal extension while simultaneously protecting the lateral meniscus. The findings of the present study will contribute toward improving surgical repairs in double-bundle PCL repairs.

Limitation of the study

The present study is conducted on a small population; a study on a larger population is desirable for aiding PCL reconstruction. As the sex of the anatomical specimen was not known, hence the gender-specific measurements could not be taken.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Clifford R. Anatomy of the Cruciate Ligament. Wheeless Textbook of Orthopaedics. Available from: http://www.wheelessonline.com/ortho/anatomy_of_the_posterior_cruciate_ligament. [Last accessed on 2015 Jan 10].  Back to cited text no. 1
    
2.
Standring S, Eliis H, Healy JC, Jhonson D, Williams A. Grays anatomy. In: Knee. 39th ed. London: Elsevier Churchill Livingstone; 2005. p. 1480.  Back to cited text no. 2
    
3.
Takahashi M, Matsubara T, Doi M, Suzuki D, Nagano A. Anatomical study of the femoral and tibial insertions of the anterolateral and posteromedial bundles of human posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2006;14:1055-9.  Back to cited text no. 3
    
4.
Clifford R. Anatomy of the Meniscofemoral Ligament. Wheeless’s Textbook of Orthopaedics. Available from: http://www.wheelessonline.com/ortho/ligaments_of_humphrey_and_wrisberg. [Last accessed 2015 Jan 10].  Back to cited text no. 4
    
5.
Amadi HO, Gupte CM, Lie DT, McDermott ID, Amis AA, Bull AM. A biomechanical study of the meniscofemoral ligaments and their contribution to contact pressure reduction in the knee. Knee Surg Sports Traumatol Arthrosc 2008;16:1004-8.  Back to cited text no. 5
    
6.
Ramos LA, de Carvalho RT, Cohen M, Abdalla RJ. Anatomic relation between the posterior cruciate ligament and the joint capsule. Arthroscopy 2008;24:1367-72.  Back to cited text no. 6
    
7.
Covey DC, Sapega AA. Anatomy and function of the posterior cruciate ligament. Clin Sports Med 1994;13:509-18.  Back to cited text no. 7
    
8.
Lee BY, Jee WH, Kim JM, Kim BS, Choi KH. Incidence and significance of demonstrating the meniscofemoral ligament on MRI. Br J Radiol 2000;73:271-4.  Back to cited text no. 8
    
9.
Nagasaki S, Ohkoshi Y, Yamamoto K, Ebata W, Imabuchi R, Nishiike J. The incidence and cross-sectional area of the meniscofemoral ligament. Am J Sports Med 2006;34:1345-50.  Back to cited text no. 9
    
10.
Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 2006;14:257-63.  Back to cited text no. 10
    
11.
Yelicharla AK, Gajbe U, Singh B. Morphometric study on cruciate ligaments of knee with gender differences: A cadaveric study. Asian Pacific J Health Sci 2014;30:289-95.  Back to cited text no. 11
    
12.
Papachristou G, Sourlas J, Magnissalis E, Plessas S, Papachristou K. ACL reconstruction and the implication of its tibial attachment for stability of the joint: anthropometric and biomechanical study. Int Orthop 2007;31:465-70.  Back to cited text no. 12
    
13.
Tansatit T, Saowaprut S, Kanchanatawan W, Chomkerd T. Pattern of angular change of the anterior cruciate ligament across the range of knee flexion and the related anatomical dimensions. J Med Assoc Thai 2005;88 Suppl 4:S95-102.  Back to cited text no. 13
    
14.
Kweon C, Lederman ES, Chhabra A. Anatomy and biomechanics of the cruciate ligaments and their surgical implications. In: Fanelli G, editor. The Multiple Ligament Injured Knee. New York: Springer; 2013.  Back to cited text no. 14
    
15.
Logterman SL, Wydra FB, Frank RM. Posterior cruciate ligament: Anatomy and biomechanics. Curr Rev Musculoskelet Med 2018;11:510-4.  Back to cited text no. 15
    
16.
LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging updates on the posterior cruciate ligament: A review of the current literature. Am J Sports Med 2015;43:3077-92.  Back to cited text no. 16
    
17.
Poynton AR, Javadpour SM, Finegan PJ, O’Brien M. The meniscofemoral ligaments of the knee. J Bone Joint Surg Br 1997;79:327-30.  Back to cited text no. 17
    
18.
Kusayama T, Harner CD, Carlin GJ, Xerogeanes JW, Smith BA. Anatomical and biomechanical characteristics of human meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 1994;2:234-7.  Back to cited text no. 18
    
19.
Gupte CM, Smith A, McDermott ID, Bull AMJ, Thomas RD, Amis AA. Meniscofemoral ligaments revisited: Incidence, age correlation and clinical implications. J Bone Joint Surg Br 2002;84:846-51.  Back to cited text no. 19
    
20.
Bintoudi A, Natsis K, Tsitouridis I. Anterior and posterior meniscofemoral ligaments: MRI evaluation. Anatomy Res Int 2012;839724:5.  Back to cited text no. 20
    
21.
Last R. The popliteus muscle and the lateral meniscus. J Bone Joint Surg [Br] 1950;32-B: 93-9.  Back to cited text no. 21
    
22.
Ebrecht J, Krasny A, Hartmann DM, Rückbeil MV, Ritz T, Prescher A. 3-Tesla MRI: Beneficial visualization of the meniscofemoral ligaments? Knee 2017;24:1090-8.  Back to cited text no. 22
    
23.
Harner CD, Xerogeanes JW, Livesay GA, Carlin GJ, Smith BA, Kusayama T, et al. The human posterior cruciate ligament complex: An interdisciplinary study. Ligament morphology and biomechanical evaluation. Am J Sports Med 1995;23:736-45.  Back to cited text no. 23
    
24.
Simonian PT, Sussmann PS, van Trommel M, Wickiewicz TL, Warren RF. Popliteomeniscal fasciculi and lateral meniscal stability. Am J Sports Med 1997;25:849-53.  Back to cited text no. 24
    
25.
Javois C, Tardieu C, Lebel B, Seil R, Hulet C. Comparative anatomy of the knee joint: Effects on the lateral meniscus. Orthop Traumatol Surg Res 2009;95S: S49-59.  Back to cited text no. 25
    
26.
Proffen BL, McElfresh M, Fleming BC, Murray MM. A comparative anatomical study of the human knee and six animal species. Knee 2012;19:493-9.  Back to cited text no. 26
    
27.
Pache S, Aman ZS, Kennedy M, Nakama GY, Moatshe G, Ziegler C, et al. Posterior cruciate ligament: Current concepts review. Arch Bone Jt Surg 2018;6:8-18.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed311    
    Printed8    
    Emailed0    
    PDF Downloaded26    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]