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Revista Romn de Anatomie funcional i clinic, macro- i microscopic i de Antropologie

UPDATES

Vol. XIII Nr. 3 2014

THE ANATOMY OF THE MENISCI


OF THE KNEE JOINT REVIEW OF THE
LITERATURE
D.E. Costin1, Al.T. Ispas2, Laura Stroic2 , V. Ardeleanu3
1. MD, Emergency Hospital of Alexandria
Romanian Handball Federation
2. University of Medicine and Pharmacy Carol Davila Bucharest
Discipline of Anatomy
3. Lower Danube University of Galati
Faculty of Medicine and Pharmacy
THE ANATOMY OF THE MENISCI OF THE KNEE JOINT REVIEW OF THE LITERATURE
(Abstract): The menisci are fibrocartilaginous, semilunar shaped structures, located in the knee
joint, that provide congruent articular surfaces of the tibia and femur. The shape of the lateral
meniscus is more like the letter O, and of the medial meniscus like the letter C. The menisci are described as having three parts: two extremities called horns - anterior and posterior - and
one body. The horns area attached by insertional ligaments to the tibial plateau. The posterior
horn of the lateral meniscus is attached to the medial condyle of the femur through the anterior
and posterior meniscofemural ligaments. This peculiarity of the lateral meniscus anatomy explains
why, during the rotation movement, the motions of the meniscus and the femoral condyle are
coupled. The lateral condyle is loosely attached through its external border to the articular capsule.
Thus, the lateral meniscus is more mobile. For the medial meniscus, the posterior horn is wider
than the anterior. The attachment areas for the anterior horn is larger than that for the posterior
horn. The dimensions of the insertional areas may be responsible for a stronger attachment, and
a lesser probability for meniscal tear, but in alliance with collagene composition and type and
insertional angle (usually a larger area means a more oblique angle of insertion). The knowledge
of the vascular and nerve supply of the menisci is very important not only for scientifical, but also
for clinical reasons. The vascular distribution is strongly correlated with the capacity of regeneration and healing. Meniscal tears that occur in the external one third of the menisci - which have
a greater vascularity are more likely to be healed. The nervous distribution may explain the
extero and proprioception at the level of the kneee joint, as well as the vasomotor reactions. Keywords: MENISCI, HORN, INSERTIONAL LIGAMENTS, KNEE

The menisci are fibrocartilaginous, semilunar shaped structures, located in the knee joint,
that provide congruent articular surfaces of the
tibia and femur.
EMBRYOLOGY
The skeleton of the human embryo has a
continuous structure with no spaces or joints
separating the main components. But as the
mesenchimal skeleton suffers the condrification
process, the second stage of bone development,
an interzone appears at the future level of the

joints. This zone had a three layers structure:


two chondrogenic layers which represent the
articular surfaces, and an intermediate layer,
from which the connection structures of a joint
develop.
The menisci develop from mesenchymal tissue and can be distinctively observed by week
8 of intrauterine life. Clark and Ogden (1, 2)
observed that at the end of the forth gestational month, the shape of the menisci is already settled. At birth, the menisci have a very
high cellular density, and also a rich vascular
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D.E. Costin et al.

network. At the age of nine weeks, the menisci


of the newborn are mostly alike the adult one,
excepting the structure. Until adolescence, a
decrease of cellularity and vascularity can be
observed, and in the same time an increase in
collagen content of the meniscus. These newly
acquired collagen fibers are oriented in order
to bear the body weight, right after the child
begins to walk. Fukazawa (3) reported that the
medial and lateral menisci development is different, as the layered structure can be observed
earlier in the lateral than the medial meniscus.
Clark and Ogden (1,2) calculated the ratio
between the meniscus surface ant the tibial plateau surface, in order to show the amount of
coverage of the articular surface of tibia. For
the medial meniscus, the ratio was between 51
and 74%, with a mean of 64%, and for the
lateral meniscus, the same ratio was 84%. Although, the surfaces of the two menisci are
almost equal. The ratio didnt show a significant change between prenatal and postnatal life,
neither a significant variation during the two
periods. The main anomaly of the menisci developmnet is the discoid meniscus, with a frequency of 1.5-4.6% for the lateral meniscus
and only 0.3% for the medial one (4).
GROSS ANATOMY
The menisci measure approximately 35 mm
in diameter (5) and the length of the rim that
attaches the meniscus to the articular capsule
is 110 mm (6). The shape of the lateral meniscus is more like the letter O, and of the
medial meniscus like the letter C. In crosssection, they are triangular in shape, as the
external heigth is 5 mm, and the inner border
is only a thin edge. They are firmly attached to
the anterior and posterior aspects of the tibial
plateau by the root ligaments. In the rabbit,
these ligaments are easy to differentiate from
the meniscal tissue by their stiffness on palpation. The attachment ligaments are very important in distributing the load at the level of knee
joint (7).
The outer borders of the menisci are convex
and attached to the articular capsule, and the
inner borders are concave and free. The superior surfaces of the menisci are concave, to
match the surface of the femoral condyles. The
inferior surface are flatter to match the tibial
condyles.
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The menisci are described as having three


parts: two extremities called horns (anterior
and posterior) and one body.
The anterior horns of the lateral and medial
menisci are attached to each other through the
transverse ligament. The insertional ligament
for the anterior horn attaches to the anterior
intercondillar eminence of the tibia, just behind
the ACL. A part of its fibers blend with the
fibers of ACL. The posterior horn of the lateral meniscus is attached to the medial condyle
of the femur through the anterior and posterior
meniscofemural ligaments, also known as Humphrey and Wrisberg ligaments. This peculiarity
of the lateral meniscus anatomy explains why,
during the rotation movement, the motions of
the meniscus and the femoral condyle are coupled. The attaching ligament of the posterior
horn is inserted on the tibial plateau, posterior
to the lateral intercondyllar eminence and anterior to the insertion of medial meniscus.
The lateral condyle is loosely attached
through its external border to the articular capsule. Because of this looseness of the capsular
attachment, and the fact that it is not attached
to the lateral colateral ligament, the lateral meniscus is more mobile. Between the capsule and
the lateral meniscus a meniscocapsular tunnel
is delimited. This tunnel is crossed by the popliteus tendon. In case of flexion and internal
rotation, the tendon retracts the posterior horn,
explaining why the lateral meniscus is more
rarely injured than the medial one.
There were described discoid lateral menisci, with complete absence of the tibial attachment of the posterior horn, so the posterior horn is attached only to the femoral condyle
via the Wrisberg ligament (8).
For the medial meniscus, the posterior horn
is wider than the anterior. The anterior horn is
firmly attached to the tibia, at 6-7mm anterior
to the anterior cruciate ligament (ACL) (6, 9).
The attaching ligament is flat and fan-shaped.
A part of its fibers blend and participate to the
transverse ligament. The posterior horn is attached in front of the attachment of the posterior cruciate ligament (PCL) and posterior to
the insertion of the lateral meniscal ligament
(6). The attachemt areas for the anterior horn
is larger than that for the posterior horn. Regarding these areas of the lateral meniscus,
there are controversies between the specialists

The Anatomy of the Menisci of the Knee Joint Review of the Literature

(6, 9). The dimensions of the insertional areas


may be responsible for a stronger attachment,
and a lesser pbobability for meniscal tear, but
in alliance with collagene composition and type
and insertional angle (usually a larger area means
a more oblique angle of insertion) (10, 11).
The external border of the medial meniscus
is attached to the articular capsule and the meniscotibial and meniscofemural ligaments attach the meniscus to the two bones, and are
known as the deep medial collateral ligaments.
MICROANATOMY
The microanatomy is very important for understanding the injury pattern. There are several types of collagen fibers dispositions. The
main pattern is a network of circumferential
fibers, which allow the dispersion of the compression loads. Another pattern is that of radial fibers, which prevent the excessive movement between the circumferential fibers and
consequently the longitudinal tear of the menisci. At the surface of the menisci, a specific
pattern cant be emphasized, the fibers being
disposed randomly (10).
FUNCTIONAL ANATOMY
The incongruency between the convex articular surfaces of the femoral condyles and the
flat articular surface of the tibial condyles is
compensated by the meniscal fibrocartilage,
with its concave superior surface directed towards the femur, and the inferior flat surface
directed towards the tibia. Thus, the menisci
significantly increase the contact surface and
the weight stresses on the tibia decrease. During in vitro experiments, the authors observed
that 70% and 50% of the loads in the knee joints
were transmitted through the lateral and medial menisci (11, 12, 13, 14 ).
These different pergentages are related to
the different amount of coverage of the articular surface of the tibia by the two menisci. The
menisci distribute forces throughout underlying
articular cartilage, thus minimizing point contact. They bear 40 to 50% of the total load
transmitted across joint in extension and 85%
of the compressive load is transmitted through
the menisci at 90 degrees of flexion (15). After
removal of the menisci, the contact areas between the femoral condyles and the tibial plateau is reduced and the sterss forces on the

tibial cartilace considerably increase. This role


of distributing load forces is possible because
of the firm anterior and posterior attachment
of the meniscal horns to the tibia. This prevent
the menisci from escaping from the knee joint
during axial loads. The load forces tension the
insertional ligaments and the circumferential
fibers of the menisci, thus transforming the
axial load into hoop stress.
This can be explained by the fact that the
circumferential collagen fibers of the meniscal
body are continuous into the horns and even
the insertional ligaments. The continuity assures for a strong bony attachment and enables
the transformation of the axial loads into hoop
stresses (11). In the rabbitt knee, the anterior
insertional ligaments were stronger than the
posterior, and the ligaments of the lateral meniscus were stronger than the medial. Based on
the idea that the amount of calcification of the
under articular cartilage cortical bone depends
on the loads that act upon it, Benjamin et al
(16) observed a thicker calcified bone in the
anterior insertional area of the lateral meniscus
than the similar zone of the medial meniscus.
The authors explain their discovery by the fact
that the fibers of the lateral anterior insertional
ligament blend with the ACL fibers and thus
the higher forces are transmitted through this
insertional area. Other specialists add that it
also means that the lateral meniscus bears higher load forces than the medial, thus its higher
force and the stronger insertional ligaments.
Messner and Gao (11) observed that the struc
ture of the anterior and posterior insertional
ligaments differs significantly. The anterior liga
ment has a typlical ligamentous structure, and
the posterior ligament has a fibrocartilaginous
structure, resembling to the meniscus. The explanation resides in the anatomical position of
these ligaments: the anterior ligament is attached
in front of the joint, and is probably affected
only by tension forces, wchich explain its ligamentous structure; the posterior ligament is
placed near the centre of the joint, being affected by both traction and compression forces.
Paletta (17) observed that transection of the
anterior and posterior insertional ligaments has
the same result over the load distribution as the
total meniscectomy. Gao and Messner (8) observed, in a rabbit model, that 6-12 weeks after
transection of anterior or posterior insertional
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D.E. Costin et al.

ligaments, the changes in bone and cartilage


structure of the tibia are similar to those that
result from a complete meniscal resection. In
contrast, after the resection of the meniscal
body, with the horns and their attacments left
untouched, the menisci continue to transmit
load forces (18). There is a linear correlation
between the surface of meniscal body removed
and the increase of the load exercised on the
tibial articular surfaces.
During flexion and extension, the lateral
meniscus moves about 10 mm, twice as much
as the medial. Meniscal motion allows maximal
congruency during knee flexion and helps to
protect the mensici from injury (15). In his
study, Vedi (19) studied meniscal movement
using a dynamic MRI. The conclusions were
that the anterior horn of medial meniscus moved
through a mean of 7.1 mm and posterior horn
through 3.9 mm, and there was 3.6 mm of
mediolateral radial displacement; the anterior
horn of the lateral meniscus moves 9.5 mm and
the posterior horn moves 5.6 mm, and there
was 3.7 mm of radial displacement.
The authors felt that the relative immobility
of the posterior horn of the medial mensicus
may account for its propensity for injury (15)
Because of the greater displacement of the anterior horn, the shapes of the menisci also
modify during the knee movements (20)
BLOOD SUPPLY AND INNERVATION
OF THE MENISCI
The arteries emerge from the lateral and
medial superior and inferior genicular arteries,
which are branches of the popliteal artery. They
reach the periphery of the meniscus through the
synovial membrane that covers the attachment
ligaments of the meniscal horns and form a
perimeniscal capillary network, from which
radial branches emerge (11). In fetal life, the
menisci have many blood vessels throughout
their entire substance. After birth, a significant
decrease in blood vessels density can be observed, begining from the internal to the external borders. In the second year of life, an avascular zone in the inner part of the menisci can
be seen. Thats why the adult meniscus is avascular in the inner two thirds (this region is
called white zone) and has a more visible vascularity in the outer one third and the adjacent

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capsular ligaments (this region is called red


zone). Another avascular zone is situated in the
external part of the lateral meniscus, adjacent
to the popliteus muscle tendon. In this area, the
popliteus tendon is placed between the lateral
meniscus and the lateral inferior genicular artery. The arterial penetration is between 10 and
30% of the width for the medial meniscus and
between 10 and 25% for the lateral meniscus.
The horns are more vascularized than the body
(11, 21, 22).
The diference in vascularity between the
fetal and adult meniscuis could explain the better regenerative and repair power of the developing meniscus.
As for the vascularity, the perimeniscal and
peripheral meniscal zones are well innervated.
There are the larger nerve fibers, which have a
circumferential course. Most of these fibers,
but not all of them are accompanied by vessels.
The smaller nerve fibers have a radial direction,
towards the external one third of the menisci.
Their pattern distribution is similar and closely associated with the vascular distribution.
Some single axons can be seen in the perimeniscal zone and in the outer one third of the menisci without vessels to accompany them. Exactly like the vessels, no nerve can be observed
in the inner two-thirds of the menisci (22). The
innervation pattern is similar for the medial and
lateral meniscus. The innervation of the horns
is greater than in the body of the meniscus.
The knowledge of the vascular and nerve
supply of the menisci is very importnant not
only for scientifical, but also for clinical reasons. The vascular distribution is strongly correlated with the capacity of regeneration and
healing, although there are several authors that
describe healing processes taking place in the
avascular zones. Meniscal tears that occur in
the external one third of the menisci - which
have a greater vascularity are more likely to
be healed. The nervous distribution may explain the extero and proprioception at the level
of the kneee joint, as well as the vasomotor
reactions. Some authors claim that the menisci
innervation is also responsible for complex actions, such as postural reflexes (22), and that
some of the pain that accompanies a meniscal
tear may originate from the meniscus itself,
espacially the peripheral lesions (23).

The Anatomy of the Menisci of the Knee Joint Review of the Literature

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