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This paper describes the anatomy of the lateral collateral ligament (LCL). The dimensions of the ligament and its femoral and fibular attachments are given. The relationships between the LCL and other anatomical structures are described, particularly the terminal fiber branches of the biceps femoris. The histological features of the ligament fibers and their osseous attachments are also described.
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Introduction
The anatomy of the lateral aspect of the knee is a
complex arrangement of static (ligaments) and dynamic
(tendons and muscles) stabilizing structures [22]. The
complexity of that anatomy is due in a large part to
the evolutionary changes in the anatomic relationship
of the fibular head, the popliteal tendon, and the bi-
ceps femoris muscle [19]. Although the function of the
ligaments is somewhat complex, their primary role is to
restrain abnormal motion. Studies have shown that the
lateral collateral ligament (LCL) is the major restraint
to primary varus rotation at all positions of knee
flexion [8]. Isolated sectioning of the LCL resulted in
at least a small but significant increase in varus rota-
tion at all angles of knee flexion. The LCL also serves
in concert with its surrounding posterolateral struc-
tures to control axial rotation of the tibia: isolated
sectioning of the LCL as well as the popliteus complex
brought about a significant increase in external tibial
rotation [14].
Biomechanics has been studied largely by cadaver
sequential sectioning studies. Selective cutting studies
have demonstrated that a section of both the pos-
terolateral structures (dividing the popliteus tendon
(PT) from the posterolateral capsular structures) and a
section of LCL result in a slight increase of posterior
translation at all angles of flexion. Studies have shown
that the posterolateral structures (popliteus, LCL, etc.)
definitely act as secondary restraints to posterior tibial
translation.
The lateral structures of the knee can be divided into
three distinct layers. The deepest layer, the lateral part of
the capsule, divides into two laminae just posterior to
the over lying iliotibial tract. These laminae encompass
three ligaments: the LCL, the fabellofibular, and the
arcuate ligaments.
The purpose of this study was to evaluate the top o-
graphical and morphological parameters of the LCL.
We have done an anatomic study based on the dissection
of cadaver knees and an analysis of the histological
sections.
Anatomic study
Materials and methods
Twenty normal cadaver knees were dissected according
to an adaptation of LaPrade and Hamiltons technique
Espregueira-Mendes
M. Vieira da Silva
Anatomy of the lateral collateral ligament:
a cadaver and histological study
Received: 15 February 2005
Accepted: 2 April 2005
Published online: 12 October 2005
Ó Springer-Verlag 2005
Abstract This paper describes the
anatomy of the lateral collateral
ligament (LCL). The dimensions of
the ligament and its femoral and
fibular attachments are given. The
relationships between the LCL and
other anatomical structures are de-
scribed, particularly the terminal fi-
ber branches of the biceps femoris.
The histological features of the lig-
ament fibers and their osseous
attachments are also described.
Keywords Lateral collateral
ligament Æ Anatomy Æ Histology
DOI 10.1007/s00167-005-0681-2
Espregueira-Mendes
Porto University, Porto, Portugal
M. Vieira da Silva
Hospital St. Anto
´
nio, Porto, Portugal
Knee Surg Sports Traumatol Arthrosc
(2006) 14: 221–228
KNEE
Espregueira-Mendes (&)
Orthopaedic Department,
Hospital S. Sebastia
˜
o, Feira, Portugal
E-mail: joaoespregueira@netcabo.pt
Fax: +351-22-6054040
[13] in order to obtain a detailed understanding of the
lateral anatomy of the knee.
There were 7 right and 13 left knees from 20 male
cadavers. The average age of the donors was 50 years
(SD 10.7, range 35–64 years old). The average weight
was 71 kg (SD 7.4 kg) and the average height was
175 cm (SD 4.3 cm). After the skin and subcutaneous
tissues of the lateral aspect of the knee were carefully
dissected away, the iliotibial band was longitudinally
incised in line with its fibers and retracted to expose
the superior aspect of the LCL and the lateral apo-
neurotic attachments of the long and short head of the
biceps femoris muscle. Once the LCL was identified,
the iliotibial band was transected and retracted both
proximally and distally so that the attachme nt of the
LCL on the femur could be identified. Dissection of
the lateral aponeurosis of the long head of the biceps
femoris muscle from the lateral an d posterio r aspect of
the LCL was then performed for better identification
of the margins of the LCL. At this point, the proximal
three-fourth of the LCL were exposed (Fig. 1). The
more distal portion of the LCL was covered by the
anterior arm of the long head of the biceps femoris
muscle. We identified the fibular colla teral ligament–
biceps femoris bursa by means of a coronal incision
between the anterior arm of the long head of the bi-
ceps femoris muscle and its lateral aponeurosis. This
incision allowed access to the most superior aspect of
the bursa. The interval between the an terior arm and
the direct arm attachment of the long head of the
biceps femoris muscle was then identified and devel-
oped further by a splitting incision between these two
structures in the sagittal plane proximal to the bursa.
Thus, the anterior arm was dissected sharply away
from the direct arm, the main tendinous unit of the
long head of the biceps femoris muscle that inserts on
the posterolateral aspect of the fibular head just lateral
to the fibular styloid. We divided the anterior arm of
the biceps approximately 5 cm proximal to the fibular
head to separate it from the main tendinous substance
of the long head of the biceps femoris muscle, and the
anterior arm of biceps was then retracted distally. This
allowed the identification of the LCL–biceps femoris
bursa as it lay deep to the anterior arm of the long
head of the bicep s femoris muscle and superficial to
the fibular collateral ligament. The attachment of the
LCL on the lateral aspect of the fibular head could
also be identified at this point (Fig. 2). Some topo-
graphical and morphological parameters were then
recorded.
Results
Total length of the ligament
The mean length was 63.1 mm (SD 5.2, range 55–
71 mm).
Shape of the proximal and distal attachments
All cases had a semicircular-shaped attachment on the
femoral condyle, with well-defined limits (Fig. 1). All
fibular attachments had a fan-like shape, with the most
lateral fibers continuing distally as a reinforcement of
the fascia over the peroneus longus muscle of the lateral
compartment of the leg (Fig. 3).
Fig. 2 The distal LCL has a bursa that separates it from the
overlying biceps
Fig. 1 The LCL is exposed after retraction of the iliotibial tract.
The distal LCL is hidden by the biceps tendon (BT )
222
Distance between the proximal attachment
and the inferior limit of the lateral femoral condyle
The mean distance between the most inferior part of the
proximal attachment and the inferior limit of the lateral
femoral condyle was 22.7 mm (SD 3.2, range 18–
30 mm) (Fig. 4).
Distance between the proximal attachment
and posterosuperior limit of the lateral femoral condyle
The mean distance between the most superior part of the
femoral attachment and the posterosuperior limit of the
femoral condyle was 13 mm (SD 2.5, range 10–18 mm)
(Fig. 5).
Distance between the proximal attachment
and the posterior limit of the lateral femoral condyle
The mean distance between the most anterior part of
the femoral attachment and the posterior limit of the
femoral condyle 32 mm (SD 2.8, range 28–36 mm)
(Fig. 4).
Size of the proximal attachment on the femoral condyle
This was measured in three planes:
Proximaldistal—10.9 mm (SD 0.1, range 10–12 mm)
Anteroposterior—10 mm (SD 0.1, range 8–12 mm)
Thickness—1.8 mm (SD 0.4, range 1–2 mm).
Relative position of the proximal attachment
of the LCL on the lateral femoral condyle
Considering a vertical line through the centre of the
proximal attachment of the LCL, the centre was situated
at 70% of its diameter from both the distal and anterior
margins (Fig. 5).
Width of the LCL at the level of the articular line
of the knee joint
This was measured in two planes:
Anteroposterior—the mean width was 8.5 mm (SD
2.2, range 5–12 mm)
Thickness—the mean thickness was 2.6 mm (SD 0.6,
range 2–4 mm).
Fig. 3 The superficial fibers of the LCL fan out distally to reinforce
the fascia overlying peroneus longus
Fig. 4 The position of the femoral attachment of the LCL in
relation to the outline of the condyle
Fig. 5 The femoral attachment was 70% of the condyle diameter
from its distal and anterior margins
223
Localization of the LCL attachment on the fibular
head
More medial fibers were inserted into a groove at the
lateral edge of the fibular head, about 1 cm anterior to
its apex, anterior to the fibular styloid. This small
saddle was approximately midway acro ss the fibular
head.
Presence of a bursa between the LCL and the biceps
femoris
In all cases a bursa was present between the distal
quarter of the LCL and the biceps femoris (Fig. 2).
According to Laprade and Hamilton [13], the bursa
forms an inverted ‘‘J’’ shape around the lateral, anterior,
and anteromedial portions of the ligament . Its distal
margin is just proximal to the fibu lar head where the
LCL inserts, and its proximal edge is at the superior
edge of the anterior arm of the long head of the biceps
femoris muscle. The functional importance of this bursa
is not clear at this time.
Dimension of the distal attachment on the fibular head
This was measured in three planes:
Proximaldistal—me an 10.9 mm, SD 1, range 10–
12 mm
Anteroposterior—mean 8.7 mm, SD 1.6, range 7–
12 mm
Thickness—mean 1.8 mm, SD 0.4, range 1–2 mm.
Angle between the LCL and the biceps femoris
With the knee at 90° of flexion, it had a mean value of
78° (SD 6, range 70–86°) (Fig. 1).
Angle between the LCL and the lateral gastrocnemius
tendon
With the knee at 90° of flexion, it had a mean value of
19° (SD 8, range 10–36°).
Angle between the LCL and the popliteal tendon
With the knee at 90° of flexion, it had a mean value of
25° (SD 5, range 12–32°) (Fig. 6).
Anatomic relation with other structures
The biceps femoris ha s an extensive, laminated, fan-
shaped tendon insertion into the head of the fibula,
LCL, and the lateral tibial condyle with expansions to
the crural fascia covering the anterior, lateral, and pos-
terior compartments of the leg [20]. The long head of the
biceps femoris has six components at the posterolateral
aspect of the knee. The anterior arm pa rtially attaches to
the distal and lateral aspect of the fibular styloid, and
then extends distally around the lateral aspect of the
LCL, sepa rated from the anterolateral distal quarter of
the LCL by a bursa (Fig. 2). After the anterior arm of
the long head of the biceps femoris passes the LCL, it
forms a fascial sheath termed the anterior aponeurosis,
which extends distally and anterolaterally over the leg
(Fig. 7). A lateral aponeurosis also extends from the
anteromedial aspect of the long head of the biceps
femoris and attaches to the posterior and lateral aspect
of the LCL proximal to the biceps bursa (Fig. 8)[13, 16,
19, 20, 22, 26].
The short head of the biceps femoris muscle has five
major components at the posterolateral aspect of the
knee. The tendinous anterior arm of the short head of
the biceps femoris extends medial to the LCL and at-
taches on the proximal lateral tibia approximately 1 cm
posterior to Gerdy’s tubercle. The distal border of the
capsular arm of the head of the biceps femoris extends
from just lateral to the tip of the fibular styloid to the
fabella or fabellar analogue and is known as the fab-
ellofibular ligament (FFL; Fig. 2). The lateral aponeu-
rosis, which is a fine aponeurotic attachment from the
main tendinous portion of the short head of the biceps
femoris, attaches onto the posteromedial aspect of the
LCL [13, 16, 19, 20 , 22].
The fabellofibular ligament descended distally and
laterally to attach on the fibular styloid from the lateral
part of the favela. If no osseous fabella was present, the
ligament’s ori gin was the posterior aspect of the su-
pracondylar process of the femur, where it blende d with
the anterior fibers of the lateral gastrocnemius tendon. It
then inserted on the fibular styloid process just posterior
to the lateral arm of the arcuate ligament [22].
Fig. 6 The LCL is at 25° to the popliteus tendon at 90° knee flexion
224
The arcuate ligament is not a single ligament but
actually several structures that combine to form an ar-
ched or arcuate appearance [22]. It is a Y-shaped
thickening of the capsule [18]. Its distal insertion is on
the apex of the fibular styloid process. It ascends verti-
cally on the free edges of the respective capsular laminae
to the lateral head of the gastrocnemius, where they are
joined by the termina tion of the oblique popliteal liga-
ment of Winslow.
The popliteus tendon (Fig. 6) arises below the LCL in
a small sulcus on the lateral femoral condyle, passes
under the LCL, descends into the popliteus hiatus, then
passes under the arcuate ligament, and becomes extra-
articular before finally joining its muscle belly, which
attaches to the posteromedial surface of the proximal
tibia. The PT sends attachments to the lateral meniscus
(the pop liteomeniscal ligament) and to the styloid pro-
cess of the fibula (the popliteofibular ligament) [22]. The
popliteomeniscal ligament prevents excessive forward
displacement of the lateral meniscus during knee exten-
sion. The popliteofibular ligament acts as a constraint
that controls the line of action of the muscle during
contraction [4, 18, 23].
The peroneal nerve enters the lateral compartment of
the leg below the termination of the distal fibers of the
LCL. There is an osseous ridge on the fibula, which
demarcates the distal LCL fibers from the peroneal
nerve. The peroneal nerve arborizes into the lateral and
anterior compartments and is located 2–3 cm below the
joint line.
Histology
Materials and methods
The tissue blocks for the histological study were ob-
tained from the attachments of the LCL on the femur
and fibula, plus the mid-third of the LCL. Extraneous
tissue was then dissected free. Anatomical landmarks
and measurements paralleling those in the cadaver
portion of the study were present in all the sectioned
specimens processed for histological staining and were
marked for future identification. We placed these spec-
imens into tissue containers.
The tissue blocks were fixed in formaldehyde for 2
days, washed, dehydrated in alcohol, embedded in
paraplast, and cut into 7-lm sectio ns for the histo-
chemical investigation. The sections were deparaffinized
in xylene and rehydrated in graded ethanol. Subse-
quently, the sections were stained with hem atoxylin and
counterstained with eosin for qualitative assessment.
Results
Microscopically, the LCL is composed of cells and ma-
trix. Most of the cells are fibroblasts, which appear as
elongated structures parallel to the matrix fibers. The
ligament contains relatively few cells, so fibroblasts
represent a small portion of the total ligament volume.
The matrix, the material that surrounds the cells, is
principally composed of regularly oriented, parallel
bundles of collagen fibers (Fig. 9). The collagen that
makes up the ligaments is grouped into bundles with a
characteristic crimp—a sinusoidal, undulating waviness
that allows the ligament to elongate or shorten slig htly
in an accordion-like fashion to adapt to external stresses.
Ligaments attach to the bone by the interdigitation of
the collagen fibers of the ligament with those of the
adjacent bone. The change from flexible ligamentous
tissue to that of a rigid bone is mediated by transitional
zones of fibrocartilage and mineralized fibrocartilage
(Fig. 9). In the fibrocartilage zone, the cells are larger
Fig. 8 A lateral aponeurosis joins the long head of the biceps to the
posterior edge of the LCL
Fig. 7 The biceps blends distally into an anterior aponeurosis
225
and more spherical than the fibroblasts of the ligament.
Analyzing the attachment of the ligament to the bone,
we think that is a direct insertion. We have seen that
most of the collagen fibrils pass directly from the sub-
stance of the ligament into the bone cortex, usually
entering at a right angle to the bone surface. These fibrils
then mingle with the collagen fibrils of the organic ma-
trix of the bone creating a strong bond between the
ligament and the bone matrix. Where dense fibrous tis-
sue structures ap proach the bone surface at oblique
angles, the colla gen fibrils may make a sharp turn to
enter the bone at a right angle. A sharp border separates
the zone of unmineralized fibrocartilage from the min-
eralized fibrocartilage zone.
Compared to other organ systems, ligaments are
relatively avascular. Some vessels penetrate ligament
surfaces and course between fibrils. These vessels come
mostly from adjacent soft tissues, with little or no con-
tribution from the ligament–bone attachments.
Discussion
Injuries to the lateral aspect of the knee are less common
than injuries to the medial structures, but may be more
disabling because they are subjected to greater force
during gait. The physiological varus angulation of the
limb axis increases and reaches maximum with full
extension of the knee during the stance phase of the gait
cycle, in which the lateral structures are stretched. Lat-
eral compartment injuries are often associated with
damage to the cruciate ligaments; isolated damage to
these structures is rare. The wide range and complexity
of these injuries cause difficulties in clinical diagnosis,
and some damaged structures may go undetected during
a clinical examination. In fact, clinically unrecognized
posterolateral injuries have been suggested as a cause of
chronic instability of the knee after trauma and post-
surgical failure of the cruciate ligaments. In severe
trauma, all the stabilizing structures of the knee may be
disrupted. In this situation, the common peroneal nerve
and the gastrocnemius muscle can also be injured [2, 10,
11, 24].
Surgeons and anatomists have named ligaments by
their location and bony attachment or by their rela-
tion to other ligaments [1, 3, 5]. The LCL is a one
rounded bundle, pencil-like cord, which is entirely
separate from the capsule of the knee joint, being an
extraarticular structure. Its femoral attachment is
semicircular, in the ‘‘saddle’’ between the lateral ep-
icondyle and the supracondylar process, above and
behind the groove for the popliteus muscle, directly
anterior to the origin of the lateral head of the gas-
trocnemius muscle, jus t proximal and posterior to the
lateral epicondyle.
The LCL is oriented slightly posteriorly and laterally as
it extends dis tally from its femoral attachment to its fib-
ular attachment. As the ligament courses distally, its more
medial fibers insert into a groove at the lateral edge of the
fibular head, about 1 cm anterior to its apex, anterior to
the fibular styloid, in a small saddle at a point approxi-
mately midway across the fibular head. The lateral fibers
of the ligament then continue distally, medial to the
anterior arm of the long head of the biceps muscle, as a
reinforcement to the fascia over the peroneus longus
muscle of the lateral compartment of the leg. The proxi-
mal part of the posterior aspect of the LCL is directly
connected to the lateral aponeurotic expansions of the
short head and is covered laterally by the lateral apo-
neurosis of the long head of the biceps muscle.
According to Sugita and Amis [21] the inclination of
the LCL relative to the antero-posterior direction in the
sagittal plane increased significantly with knee flexion
from 74±3 ° at 0° of knee flexion to 96±13° at 90° of
knee flexion. The LCL passed through vertical at
approximately 70° of knee flexion.
In our study, the LCL had a mean length of 63 mm.
The length reduced significantly and slackened as the
knee flexed. The length at 90° of knee flexion was sig-
nificantly less than at 0° . The LCL resists tibial external
rotation immediately from neutral tibial rotation at 0° of
knee flexion. However, nearly 40° of external tibial
rotation is required before it becomes taut at 90° of knee
flexion, so the popliteofibular ligament complex is
dominant and will rupture before the LCL in this situ-
ation. Abnormal increased external tibial rotation at 90°
of knee flexion does not mean that the LCL is damaged,
because a large external rotation is needed to even bring
Fig. 9 A histological section slowing the LCL fibers attaching to a
bone via an intermediate fibrocartilagenous layer (H&E stain)
226
it to the slack–taut transition point [21]. The LCL is the
primary passive restraint to varus tibial rotation
(adduction) with the knee extended [8], so this test must
be applied to check LCL integrity. The LCL is a sec-
ondary restraint of posterior translation. Coupled
external rotation and lateral translation accompany
posterior translation. The isolated loss of the posterior
cruciate ligament results in an increase in posterior
translation to a maximum of 15–20 mm at 90° knee
flexion as well as a loss of couple d external rotation.
When the posterior aspect of the capsule, the postero-
lateral structures, and the LCL are sectioned, however,
the coupled external rotation is increased. No change
occurred in posterior translation after the isolated sec-
tion of the LCL [ 6, 8, 9, 12, 25].
The LCL appears to be dynamically controlled by the
actions of the short and long heads of the biceps femoris
and their attachment to the LCL. This can be demon-
strated in vivo by applying a muscle stimulator to the
muscle fibers of the short head of the biceps femoris and
observing its bowstring effects on the LCL during its
contraction [13].
Sugita and Amis [21] found the tensile strength of the
LCL to be 309 N, whereas Maynard et al. [17] found itto be
750 N. It is possible that the lower strength seen in Sugita’s
study was due to a more complete dissection of the over-
lying fascial tissue and not due to the specimen’s age.
Importance of clinical anatomy
The reconstructive surgeon of today must know the
anatomy and understand the key principles of normal
ligament function to be able to restore the injured knee
to its previous level of performance. The lateral com-
partment of the knee has a complex and variable anat-
omy, and the results of reconstructive surgery have been
inconsistent. However, there has recen tly been an
increasing awareness of the importance of the structures
crossing the lateral and posterolateral corner of the knee
in providing function. One of the factors that makes
surgery of the lateral and posterolateral corner so diffi-
cult, and hence limits its success, is its anatomical vari-
ability. Watanabe et al. [26] examined the incidence of
different posterolateral stru ctures and found a pop-
liteofibular ligament in 94% of the115 knees; they
showed that different combinations among the LCL,
popliteofibular, arcuate, and FFLs can be encountered
in different knees.
Repair and reconstruction of the LCL, popliteofibu-
lar ligament, or both, dependon the assessment of what
has been damaged. Attention is focused on these struc-
tures because the LCL is a primary restraint against
varus (adduction) angulation [8] and the popliteofibul ar
ligament against tibial external rotation [17 ].
The knowledge of this anatomy and how variable the
structures of this part of the knee can be is necessary for
the treatment of acute injuries to the lateral aspect of the
knee joint, especially for reconstruction necessitated by
lesions that cause chronic rotatory instability of the
knee. With a firm understanding of the anatomy of the
lateral knee, one may understand the underlying
importance of the diagnosis and treatment of a lateral
and posterolateral knee ligament injury. Further ad-
vances in understanding and research regarding the
posterolateral knee are dependent on a uniform
description of anatomic structures.
Acknowledgments The authors express their extreme gratitude to
Servic¸ o de Anatomia Patolo
´
gica do HGSA-Porto (Dr. Isabel
Calhim) for the histologic preparation and evaluation and Insti-
tuto de Medicina Legal do Porto for the cadavers used for dis-
section.
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198:199–204
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... The main role of the FCL is to resist varus forces at all knee flexion angles; however it tends to resist tension when at an angle between 0 • -30 • , and counters external rotation when near to full extension (Espregueira-Mendes and Vieira Da Silva, 2006;Gollehon et al., 1987;Grood et al., 1988;LaPrade et al., 2004;Moulton et al., 2015). Thus, it is subjected to the greatest force during the stance phase of the gait (Chappell et al., 2014;Espregueira-Mendes and Vieira Da Silva, 2006;Kim et al., 2013). ...
... The main role of the FCL is to resist varus forces at all knee flexion angles; however it tends to resist tension when at an angle between 0 • -30 • , and counters external rotation when near to full extension (Espregueira-Mendes and Vieira Da Silva, 2006;Gollehon et al., 1987;Grood et al., 1988;LaPrade et al., 2004;Moulton et al., 2015). Thus, it is subjected to the greatest force during the stance phase of the gait (Chappell et al., 2014;Espregueira-Mendes and Vieira Da Silva, 2006;Kim et al., 2013). The injury of the FCL develops as a results of various types of stress and hyperextension. ...
... The injury of the FCL develops as a results of various types of stress and hyperextension. It is most often injured after a direct hit to the medial side of the knee, although a lesion can develop after a strong strike to the lateral part of the foot or a non-contact injury in this same pattern of movement (Chappell et al., 2014;Espregueira-Mendes and Vieira Da Silva, 2006;Moulton et al., 2015). Although tennis players or gymnasts are most vulnerahttps://doi.org/10.1016/j.aanat.2018.10.009 ...
Article
Background The fibular collateral ligament (FCL) is subject to varus forces at all knee flexion angles and is also resistant to external rotation near extension. It originates on the lateral epicondyle of the femur and inserts on the lateral surface of the head of the fibula. However, its anatomical characteristics are inconsistent. Recent publications have focused on morphological variations concerning mainly femoral and fibular attachments, as well as morphometric measurements. Less attention has been paid to the morphology of the FCL and its relationship to the antero-lateral ligament (ALL). Question/Purposes The aim of this paper is therefore to introduce the first complete classification of the FCL that includes all important aspects of morphological variability. Methods Classical anatomical dissection was performed on 111 lower limbs (25 isolated and 86 paired) fixed in 10% formalin solution. The lateral compartment of the knee was investigated in detail. Results The fibular collateral ligament was present in all specimens. The FCL originated most commonly (72.1% of cases) from the lateral femoral epicondyle, and the inserted on the lateral surface of the head of the fibula (Type I). In addition, bifurcated (Type IIa − 12.6%) and trifurcated (Type IIb − 0.9%) ligaments were also found with two and three distal bands, respectively. A double FCL was also found (Type III − 6.3%), as was fusion of the FCL and ALL (Type IV − 8.1%). Conclusion The FCL is characterized by high morphological variability. Knowledge of these variants is essential for surgeries performed in this region concerning the FCL and the ALL. Clinical Relevance Distinguishing FCL from the FCL-ALL Complex is necessary when planning surgical procedures.
... Considering the surgical and functional importance of the posterolateral corner of the knee (PLC), in recent years there has been increasing interest in the region. Injuries of PLC are surgically important as playing major role against varus rotation, external rotation and posterior tibial translation (LaPrade et al., 2003;Brinkman et al., 2005;Espregueira-Mendes & da Silva, 2006& James et al., 2015. Among the numerous lateral structures of the knee, the lateral (fibular) collateral ligament (LCL), popliteus tendon (PT) and popliteofibular ligament (PF) are the key structures for posterolateral stability (LaPrade et al.). ...
... Our finding about the length of LCL was similar to previous studies, as shown in Table II (Maynard et al., 1996;Ishigooka et al., 2004;Espregueira-Mendes & da Silva;Zhang et al., 2009;Jung et al.;Osti et al.). In most of the cases, LCL was wider at the upper part and narrower at the lower part, in accordance with the findings of Takeda et al. ...
... Regarding the presence and form of bursa, the cases were evaluated in four types as absent, sac form lying superficial to LCL, vagina synovialis form and bursa lying deep to LCL. Even though the presence of a LCL-biceps femoris bursa was mentioned(LaPrade & Hamilton, 1997;Brinkman et al.;Espregueira-Mendes & da Silva;Song et al., 2014) a vagina synovialis which embraced superficial, anterior and deep surfaces of the distal part of LCL has not been mentioned enough in the literature, except one(Fig. 3b). ...
Article
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KURTOGLU, Z.; ELVAN, O; AKTEKIN, M. & ÇOLAK, M. Morphological features of the popliteus tendon, popliteofibular and lateral (fibular) collateral ligaments. Int. J. Morphol., 35(1):62-71, 2017. SUMMARY: To reveal the detailed morphological features of the fibular collateral (fibular) ligament, popliteus tendon, popliteofibular ligament and the synovial components regarding to achieve data for surgical and biomechanical utilization. Knees of 10 formalin-fixed male cadavers were dissected bilaterally. Bursae around the lateral collateral ligament and the relation of popliteus tendon with lateral collateral ligament at the femoral attachment site were noted. The positional relation between both ends of popliteofibular ligament was evaluated statistically. The PT exceeded the anterior margin of lateral collateral ligament in 11 sides, the posterior margin of lateral collateral ligament in 3 sides and exceeded both the anterior and posterior margins of lateral collateral ligament in 5 sides. The shape of lateral collateral ligament was narrower at the lower part than the upper in 14 sides. The width of lower part of lateral collateral ligament was found narrower in the cases with sheath-like bursa (vagina synovialis). The relation between both ends of popliteofibular ligament was as followed: the more anteriorly the fibular head attachment was located, the more anteriorly popliteofibular ligament was attached to the popliteus tendon. To resolve the posterolateral corner of the knee with regard to surgical anatomy and biomechanics, individual and concerted morphometric characteristics of lateral collateral ligament, popliteus tendon and PF should be evaluated together with accompanied synovial structures.
... Os ligamentos colaterais lateral e medial do joelho das pacas são constituídos por tecido conjuntivo denso modelado em grande parte de sua extensão, assim como descrito para os ligamentos cruzados cranial e caudal para o ligamento colateral medial, para o tendão patelar e para o tendão calcâneo comum de coelhos da raça Nova Zelândia (Amiel et al. 1984); para o ligamento colateral lateral de seres humanos (Mendes & Silva 2006) e para o ligamento cruzado cranial de ovinos (Meller et al. 2009). A predominância de fibroblastos dispostos em fileiras, paralelas aos feixes de fibras colágenas, verificada nos ligamentos cruzados cranial e caudal, no ligamento colateral medial, no tendão patelar e no tendão calcâneo comum de coelhos da raça Nova Zelândia (Amiel et al. 1984); no ligamento colateral lateral de seres humanos (Mendes & Silva 2006) e no ligamento cruzado cranial de ovinos (Meller et al. 2009) também foi observada nos ligamentos colaterais lateral e medial do joelho da paca. ...
... Os ligamentos colaterais lateral e medial do joelho das pacas são constituídos por tecido conjuntivo denso modelado em grande parte de sua extensão, assim como descrito para os ligamentos cruzados cranial e caudal para o ligamento colateral medial, para o tendão patelar e para o tendão calcâneo comum de coelhos da raça Nova Zelândia (Amiel et al. 1984); para o ligamento colateral lateral de seres humanos (Mendes & Silva 2006) e para o ligamento cruzado cranial de ovinos (Meller et al. 2009). A predominância de fibroblastos dispostos em fileiras, paralelas aos feixes de fibras colágenas, verificada nos ligamentos cruzados cranial e caudal, no ligamento colateral medial, no tendão patelar e no tendão calcâneo comum de coelhos da raça Nova Zelândia (Amiel et al. 1984); no ligamento colateral lateral de seres humanos (Mendes & Silva 2006) e no ligamento cruzado cranial de ovinos (Meller et al. 2009) também foi observada nos ligamentos colaterais lateral e medial do joelho da paca. ...
Article
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RESUMO: A paca (Cuniculus paca), um dos maiores roedores da fauna brasileira, possui características inerentes à sua espécie que podem contribuir como uma nova opção de animal experimental; assim, considerando-se que há crescente busca por modelos experimentais apropriados para ortopedia e pesquisas cirúrgicas, foram analisados e descritos em detalhes a anatomia microscópica e ultraestrutural do joelho desse roedor. Os ligamentos colaterais são constituídos por feixes de fibras colágenas arranjadas paralelamente e com trajeto ondulado. Os fibroblastos formavam fileiras paralelas às fibras colágenas; quanto aos ligamentos colaterais, estes apresentaram citoplasma imperceptível à avaliação por microscopia de luz, entretanto, em análise ultraestrutural verificou-se vários prolongamentos citoplasmáticos. Microscopicamente, as estruturas presentes no joelho da paca assemelham-se às dos animais domésticos, roedores e lagomorfos.
... The LCL, also termed the fibular ligament, is one of the critical stabilizers of the knee joint. Originating on the lateral epicondyle of the femur and inserting on the fibular head, the primary function of LCL is to prevent excess varus stress and postero-lateral rotation (Espregueira and da Silva, 2006;Grood et al., 1981). ...
Article
Background The human knee is a complex joint, and affected by a variety of articular cartilage disorders. Large animal models are critical to model the complex disease mechanisms affecting a functional joint. Species-dependent differences highly affect the results of a pre-clinical study and need to be considered, necessitating specific knowledge not only of macroscopic and microscopic anatomical and pathological aspects, but also characteristics of their individual gait and joint movements. Methods Literature search in Pubmed. Results and discussion This narrative review summarizes the most relevant anatomical structural and functional characteristics of the knee (stifle) joints of the major translational large animal species, comprising dogs, (mini)pigs, sheep, goats, and horses in comparison with humans. Specific characteristics of each species, including kinematical gait parameters are provided. Considering these multifactorial dimensions will allow to select the appropriate model for answering the research questions in a clinically relevant fashion.
... Moreover, it resists external rotation of the knee over the flexion span 0°-30°. Above 30° it loses tension and becomes insufficient as a stabilizer of external rotation of the knee [5,8,10,15,20]. It is possible that some kinds of multibanded FCL can provide extra stabilization functions, but specialist biomechanical examination will be needed to establish this. ...
Article
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Background: The fibular collateral ligament is a permanent and extracapsular ligament of the knee joint. It is located on the lateral aspect of the knee and extends from the lateral epicondyle of the femur to the lateral surface of the head of the fibula. As one of the main knee joint ligaments it is a stabilizer of the posterolateral corner of the knee and resists varus stress. The case report displays the bifurcated variant of the fibular collateral ligament. The aim of this study is to determine which of those bands should be considered dominant. Materials and methods: Classical anatomical dissection was performed on the left knee joint. The fibular collateral ligament was thoroughly cleansed around its origin, distal attachments, and course. Appropriate morphometric measurements were collected. Results: A bifurcated variant of the fibular collateral ligament with inverted proportions of its two bands (main and accessory one) constitutes our findings. It originated on the lateral epicondyle of the femur. Then it divided into two bands (A1 and A2). Band A1 inserted to the head of the fibula. A bony attachment of band A2 was located on the lateral aspect of the lateral condyle of the tibia. Conclusions: Although the fibular collateral ligament is a permanent structure it presents morphological variations. It is important to constantly extend morphological knowledge for all scientists concerned in anatomy.
Article
The agouti (Dasyprocta prymnolopha, Wagler 1831) is a wild rodent of great zootechnical potential, a fact that enables anatomical and morphological studies to support management actions with this animal. In this perspective, this study aimed to describe the anatomy and histology of the agouti stifle joint. Four adult agoutis were used, two females and two males. The animals were submitted to dissection and identification of the structures of the stifle joint. For light microscopy study, samples of the patellar ligament, cranial and caudal cruciate ligaments, medial and lateral collateral ligaments were used. Agouti has a highly congruent patellofemoral joint; elongated patella; medial and lateral fabellae at the proximal insertion of the gastrocnemius muscle; medial and lateral meniscus with lunula; in addition to the presence of the following ligament structures: patellar ligament, cranial and caudal cruciate ligaments, medial and lateral collateral ligaments, meniscofemoral ligament, caudal meniscal ligament of the medial meniscus, and medial and lateral cranial ligaments. The patellar ligament presents bundles of parallel collagen fibers with a straight path and coated fibroblasts; collateral and cruciate ligaments had loose and dense connective tissue, coated fibroblasts and collagen bundle undulations, the latter most expressive in the caudal cruciate ligament. Thus, except for the shape and angulation of the stifle, which allows specific movements, the agouti stifle has structures analogous to that of other rodents and domestic animals. Through a macroscopic analysis going to a microscopic view of the agouti knee, macro similarity is verified with other rodents, and the micro patellar ligament presents bundles of parallel collagen fibers with a straight path and coated fibroblasts, collateral and crossed ligaments with loose and dense connective tissue, coated fibroblasts, and collagen bundle undulations.
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Rodilla es un libro que refleja el esfuerzo de casi treinta profesionales por ordenar y actualizar las materias más frecuentes que se ven en esta especialidad. Los treinta y tres capítulos distribuidos a lo largo de cuatrocientas páginas están dirigidos a todos aquellos que se interesen por los problemas clínicos de esta articulación, que en general concentra un alto número de consultas e intervenciones en cualquier equipo de Traumatología. Sin embargo, pensamos que va a ser especialmente útil para los residentes en formación, los traumatólogos generales y aquellos que inician sus pasos en la subespecialidad.
Chapter
Posterolateral corner (PLC) and lateral (fibular) collateral ligament (LCL/FCL) injuries of the knee are more common than has previously been reported. Well-conducted in vivo and in vitro studies by LaPrade and colleagues have improved our understanding of the surgical anatomy of PLC injuries. However, much is still unknown regarding these injuries, such as the extent of disability, the exact pathogenesis and the optimal surgical technique, to name but a few. There are a variety of surgical techniques for grade III PLC injuries. However, it is still unknown whether the different surgical techniques yield different outcomes. There is consensus about the diagnostic evaluation, as well as imaging. There is also consensus that reconstruction is to be preferred to repair alone and that an early reconstruction will yield better results than surgery performed on chronic cases. Malalignment should always be considered, especially in chronic cases, and osteotomy must always be performed before or simultaneously with ligament reconstruction to reduce the risk of secondary graft failure. Most grade I and II PLC injuries are probably treated non-surgically, but the long-term outcome for this patient group is unknown. Non-surgically treated grade III PLC injuries will lead to poor function and the development of osteoarthritis in the medium term. For this reason, grade III injuries (with more than a 4 mm gap in the lateral joint line, compared with the other side) should always be treated surgically with reconstruction of the three important stabilising structures: the LCL/FCL, the popliteal tendon and the popliteo-fibular ligament (PFL).
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Lateral instability of the knee is less frequent but more disabling than medial instability of a comparable amount. At the same time the diagnostic tests for lateral instability are more subtle and more frequently misinterpreted. Posterolateral rotatory subluxation is demonstrated by an apparently positive posterior drawer test with the tibia in neutral rotation or by the external rotation-recurvatum test with the knee in extension. Anterolateral rotatory subluxation is present when the anterior drawer test with the tibia in neutral rotation demonstrates that the lateral tibial condyle appears to become more prominent or that both condyles appear to become equally prominent.
Chapter
Given the major significance of posterolateral structures in reconstructive surgery of the knee ligaments, it is important to have a precise understanding of their anatomy.
Article
The posterior aspect of forty cadaver knees was dissected to determine the proximal insertion of the popliteus tendon, particularly its relationship to the lateral meniscus. Thirty-three (82.5 per cent) of the specimens demonstrated no major attachment of the popliteus tendon to the lateral meniscus. Eight specimens were from bilateral dissections and revealed no major asymmetry. On the basis of these dissections, we found no evidence that the popliteus tendon has a role in the retraction and protection of the lateral meniscus.
Article
We applied specific forces and moments to the knees of fifteen whole lower limbs of cadavera and measured, with a six degrees-of-freedom electrogoniometer, the position of the tibia at which the ligaments and the geometry of the joint limited motion. The limits were determined for anterior and posterior tibial translation, internal and external rotation, and varus and valgus angulation from zero to 90 degrees of flexion. The limits were measured in the intact knee and then the changes that occurred with removal of the posterior cruciate ligament, the lateral collateral ligament, the popliteus tendon at its femoral attachment, and the arcuate complex were measured. The cutting order was varied, allowing us to determine the changes in the limits that occurred when each structure was cut alone and the amount of motion of the joint that was required for each structure to become taut and to limit additional motion when the other supporting structures had been removed. Removal of only the posterior cruciate ligament increased the limit for posterior tibial translation, with no change in the limits for tibial rotation or varus and valgus angulation. The additional posterior translation was least at full extension and increased progressively, reaching 11.4 millimeters at 90 degrees of flexion. The progressive increase in posterior translation with flexion was apparently due to slackening of the posterior portion of the capsule, as the translation nearly doubled when the posterolateral structures subsequently were removed. Removal of only the posterolateral extra-articular restraints increased the amount of external rotation and varus angulation. The average increase in external rotation depended on the angle of flexion; it was greatest at 30 degrees of flexion and decreased with additional flexion. At 90 degrees of flexion, the intact posterior cruciate ligament limited the increase in external rotation to only 5.3 degrees, less than one-half of the 13.0-degree increase that occurred at 30 degrees of flexion. Subsequent removal of the posterior cruciate ligament markedly increased external rotation at 90 degrees of flexion, resulting in a total increase of 20.9 degrees. The limit for varus angulation was normal as long as the lateral collateral ligament was intact. When the lateral collateral ligament was cut, the limit increased 4.5 degrees (approximately 4.5 millimeters of additional joint opening) when the knee was partially flexed (to 15 degrees).(ABSTRACT TRUNCATED AT 400 WORDS)
Article
Injury to the posterolateral structures of the knee, including the popliteus tendon and arcuate complex, frequently results in poorly understood patterns of instability. To evaluate the static function of these tissues, we used a mechanical testing apparatus that allowed five degrees of freedom to test seventeen specimens from human cadavera at angles of flexion that ranged from zero to 90 degrees. Selective section of the lateral collateral ligament, popliteus-arcuate (deep) ligament complex, anterior cruciate ligament, and posterior cruciate ligament was performed. At all angles of flexion, the lateral collateral ligament and deep ligament complex functioned together as the principal structures preventing varus rotation and external rotation of the tibia, while the posterior cruciate ligament was the principal structure preventing posterior translation. However, at angles of flexion of 30 degrees or less, the amount of posterior translation after section of only the lateral collateral ligament and the deep structures was similar to that noted after isolated section of the posterior cruciate ligament. Isolated section of the posterior cruciate ligament did not affect varus or external rotation of the tibia at any position of flexion of the knee. When the posterior cruciate ligament was sectioned after the lateral collateral ligament and deep ligament complex had been cut, a large increase in posterior translation and varus rotation resulted at all angles of flexion. In addition, at angles of flexion of more than 30 degrees, external rotation of the tibia also increased. The application of internal tibial torque resulted in no increase in tibial rotation after isolated section of the anterior cruciate ligament or combined section of the lateral collateral ligament and deep ligament complex. However, combined section of all three structures increased internal rotation at 30 and 60 degrees of flexion. The increases in external rotation that were produced by section of the lateral collateral ligament and deep ligament complex were not changed by the addition of the section of the anterior cruciate ligament.
Article
Posterolateral rotatory instability of the knee, usually accompanied by other instabilities, is easily missed, misdiagnosed, and mistreated. The correct diagnosis requires a complete examination of the knee, including both the external rotation-recurvatum and posterolateral drawer tests. The most effective operative approach when the lesion is interstitial or at the site of the femoral attachment consists of advancing the arcuate ligament complex and its osseous attachment anteriorly and distally on the femur to support the arcuate ligament repair. When the lesion is distal and the arcuate ligament attachment to the tibia and fibula is loose, this area must be stabilized. In a consecutive series of 140 patients, 141 knees were reconstructed with this procedure. Ninety-five patients (ninety-six knees), with a follow-up of two to thirteen years, form the basis for this report. Seventy-one of the patients had undergone a combined total of 112 prior operations on the knee without functional recovery. After surgery directed at the arcuate ligament complex, eighty-two knees (85 per cent) were objectively rated as good; thirteen (14 per cent), as fair; and one, as poor. Subjectively, seventy-five (78 per cent) of the patients considered the result to be good; twenty-one (22 per cent), fair; and none, poor. Functionally, seventy-seven (80 per cent) of the knees were rated by the patient as good; sixteen (16 per cent), as fair; and three (4 per cent), as poor. This is the first report on the long-term results of reconstruction of the arcuate ligament complex for the correction of chronic posterolateral rotatory instability. The results demonstrate the effectiveness of the procedure.
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There is still a long way to go to achieve the goals of ligament replacement through modification of normal, intrinsic ligament healing processes. We are learning about the biology of ligamentous tissues, including the problem of regeneration, and that in itself is an all-important first step toward seeking solutions.