Rev. bras. ortop. vol.48 número5

(1)

rev bras ortop.2013;48(5):412–416

w w w . r b o . o r g . b r

Original

Article

Anatomical

relationships

between

Wrisberg

meniscofemoral

and

posterior

cruciate

ligament’s

femoral

insertions

夽

,

夽夽

Heetor

Campora

de

Sousa

Oliveira

a,∗

,

Julio

Cesar

Gali

b

,

Edie

Benedito

Caetano

c a_Former_Resident_at_the_Sorocaba_School_of_Medical_Sciences_and_Healthcare,_Pontifícia_Universidade_Católica_de_São_Paulo

(FCMS-Sorocaba/PUC-SP);VoluntaryAttendingPhysicianintheOrthopedicsandTraumatologyService,FCMS-Sorocaba/PUC-SP, Sorocaba,SP,Brazil

b_PhD_in_Orthopedics_and_Traumatology_from_the_School_of_Medicine,_University_of_São_Paulo;_Voluntary_Attending_Physician_in_the

OrthopedicsandTraumatologyService,FCMS-Sorocaba/PUC-SP,Sorocaba,SP,Brazil

c_Full_Professor_and_Head_of_the_Orthopedics_and_Traumatology_Service,_{FCMS-Sorocaba/PUC-SP,}_Sorocaba,_SP,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received11June2012

Accepted14August2012

Keywords:

Femur

Posteriorcrucianteligament

Tibialmenisci

a

b

s

t

r

a

c

t

Objective:ToevaluatethefrequencyandmorphometryoftheWrisberg’sligamentandits

relationshipswiththeposteriorcruciateligament’sfemoralinsertion.

Studydesign:Controlledlaboratorystudy.

Methods:24unpairedkneepieces,12rightand12leftweresubmittedtoadeepdissectionof

theWrisbergandposteriorcruciateligaments.Thepieceswerephotographedwithadigital

cameraandruler;theImageJsoftwarewasusedtomeasuretheligaments’insertionareas,

insquaremillimeters.

Results:TheWrisbergligamentwaspresentin91.6%ofthestudiedpieces.Inthoseitsshape

wasellipticalin12pieces(54.54%).In68%oftheknees,theWLinsertionwasproximalto

themedialintercondilarridge,closetothePCLposteromedialbundle.Theaverageareafor

theWLwas20.46±6.12mm2_._This_number_corresponded_to_23.3%_of_the_PCL’s_average_area.

Conclusions:WLligamentisacommonstructureinknees.Thereisawidevariationofits

insertionarea.ProportionallytothePCL’sinsertionareatheWLonessuggeststhatitmay

contributetotheposteriorstabilityofthekneejoint.

Ltda.Allrightsreserved.

夽_Please_cite _this_article_as:_Oliveira _HCdS,_Gali_JC, _Caetano_EB. _Relac¸ões_anatômicas_entre_as_inserc¸ões_femorais _dos _ligamentos

meniscofemoraldeWrisbergecruzadoposterior.RevBrasOrtop.2013;48;412–416.

夽夽

StudyconductedattheSorocabaSchoolofMedicalSciencesandHealthcare,PontifíciaUniversidadeCatólicadeSãoPaulo,Sorocaba,

SP,Brazil.

∗ _{Corresponding}_author_at_:_Av._Eugênio_Salerno,_387,_CEP_18035-430,_Sorocaba,_SP,_Brazil._Fax:₊₁₅₃₂₂₉_0202.

E-mail:hectormed@bol.com.br(H.C.d.S.Oliveira).

(2)

Relac¸ões

anatômicas

entre

as

inserc¸ões

femorais

dos

ligamentos

meniscofemoral

de

Wrisberg

e

cruzado

posterior

Palavras-chave:

Fêmur

Ligamentocruzadoposterior

Meniscostibiais

r

e

s

u

m

o

Objetivo: AvaliarafrequênciaeamorfometriadoligamentomeniscofemoraldeWrisberge

arelac¸ãodesuasinserc¸õesfemoraiscomaquelasdoligamentocruzadoposterior(LCP).

Desenhodoestudo: Estudolaboratorialcontrolado.

Métodos: Foramfeitasdissecc¸õesminuciosasdasinserc¸õesfemorais dosligamentosde

Wrisberg(LW)edoLCPem24pec¸asanatômicasdejoelhos.Aspec¸asforamfotografadas

comumacâmeradigitalemarcadormilimetrado;oprogramaImageJfoiusadoparamedir

aáreadasinserc¸õesligamentares,emmilímetrosquadrados.

Resultados: OLWestevepresenteem91.6%daspec¸asestudadas.Nessas,seuformatofoi

elípticoem12pec¸as(54.54%).Em68%dosjoelhosainserc¸ãodoLWesteveproximalàcrista

intercondilarmedial,próximoàbandaposteromedialdoLCP.Aáreamédiadainserc¸ão

femoraldoLWfoide2046±6.12mm2_,_o_que_correspondeu_a_23.3%_da_área_de_inserc¸ão_do

LCP.

Conclusões: OLWéestruturafrequentenosjoelhos,comgrandevariabilidadedesuaárea

média.ProporcionalmenteaoLCP,suaáreamédiasugerequeesseligamentopodecontribuir

paraaestabilidadeposteriordojoelho.

EditoraLtda.Todososdireitosreservados.

Introduction

The posterior meniscofemoral ligament, or Wrisberg

liga-ment, goes from the lateral aspect of the medial femoral

condyletotheposteriorcornuofthelateralmeniscus.Ithas

aposteriorlocationthatisveryclosetotheposteriorcruciate

ligament(PCL),withaslightlymoreobliquedirection(Fig.1).

Itsfrequencyofoccurrenceinhumansranges from90% to

93%.1–3

Thefirst descriptionofthe meniscofemoral ligament in

the medicalliterature was madeby Humphreyin 1858.In

1899,PoirierandCharpyreportedtwodistinctstructuresthat

Fig.1–Deepdissectionshowingtheposteriorcruciate ligament(PCL),Humphreymeniscofemoralligament(H), Wrisbergligament(W)andlateralmeniscus(LM).

startedfromtheposteriorcornuofthelateralmeniscusand

involvedthePCL(apudGupteetal.4_).

Studies conducted more recently have also shown the

Wrisbergligamentformspartofacomplextogetherwiththe

PCLandremainstenseduringkneeextension.Itcontributes

towardposteriorstabilityandtowardharmoniousmovement

ofthelateralmeniscusduringflexionand extensionofthe

knee.5,6

Together with the anterior meniscofemoral ligament, it

actsasasecondarylimiterofposteriortranslationofthetibia,

anditaccountsfor35–45%ofthisactionwiththekneeflexed

at90◦_.6,7

Theobjectiveofourstudywastoevaluatethefrequencyof

occurrenceoftheWrisbergligamentinthespecimens

ana-lyzed, the shape and area of its femoral insertion and its

relationshipwiththePCL.Inthismanner,wehopedtobeable

tocontributetowardexpandingtheanatomicalknowledgeof

theposteriorstabilizingcomplexoftheknee.

Methods

Twenty-fourunpairedanatomicalspecimensofadultknees

fromcadaverswerestudied(12rightkneesand12leftknees).

Allofthespecimenspresentedintactcruciateligamentsand

joint cartilage. None of the knees presented any signs of

arthrosis.Thespecimensusedhadbeenfixedin10%formol

andwereconservedinamixtureof2.5%phenol,2.5%formol

and1%sodiumchloride.

Weperformeddetaileddissectionoftheposterioraspect

ofthekneeusingascalpelwithaNo.11blade.Weisolated

theWrisbergligament,themenisciandthePCL,andwealso

identifiedtheanterolateralandposteromedial bandsofthe

PCL.

AfterisolatingtheWrisbergligamentandthebandsofthe

(3)

414

rev bras ortop.2013;48(5):412–416

Fig.2–Lateralviewofthemedialfemoralcondyleshowing themedialintercondylarridge,thefemoralinsertionsof theWrisbergligament(W)andtheanterolateral(AL)and posteromedial(PM)bandsofthePCL.

astohavebetterviewingofthestructures,andwedelimited

theirareasofinsertion.

Weusedamillimeterrulerplacedasthesamelevelasthe

insertionsandwephotographedthespecimensusingaCanon

EOSRebelT1idigitalcamera(Fig.2).Sincetheinsertionsofthe

WrisbergligamentandthePCLbandsarenotlocatedexactly

inthesameplane,theimageswereproducedas

perpendicu-larlyaspossibletotheanatomicalstructures,accordingtothe

regiontobestudied.

TheImageJsoftwarewasusedtocalculatethe

measure-mentsofinterest,inmillimetersorinsquaremillimeters.

Results

TheWrisbergligamentwasidentifiedin22ofthe24

speci-mensanalyzed(91.6%).Inthese,itsshapewasellipticalin12

specimens(54.54%).

Itsmean areaofinsertionwas20.26±6.12mm2 _and_the

mean area of insertion of the PCL was 87.80±28.21mm2_.

The mean areas of insertion of the anterolateral and

posteromedial bands were, respectively, 47.13±19.14 and

40.67±16.19mm2_.

In68% ofthe knees,the insertionofthe Wrisberg

liga-mentwasproximaltothemedialintercondylarridge.Inmost

ofthespecimens(90.9%),theWrisbergligamentwascloser

to the posteromedial band than to the anterolateral band

(mean distancesbetween the insertioncenters of9.15mm

and14.18mm,respectively),althoughintwospecimensthe

situationwasthe inverse,probablybecauseofan

anatomi-calvariationinthelayoutofthePCLbandsthatpredisposed

towardthissituation(Fig.3).

Themeandistancesfromthecenteroftheareaof

inser-tionoftheWrisbergligamenttotheposterioranddistaljoint

cartilage ofthe medialfemoral condylewere 7.05mm and

10.16mm,respectively.Table1showsthemeansfoundinour

study.

Fig.3–Lateralviewofthemedialfemoralcondyleshowing thecenterofthefemoralinsertionoftheWrisbergligament (W)andtheanterolateral(AL)andposteromedial(PM) bandsofthePCL.

Discussion

The number of studies relating to the PCL has increased

substantially in the medical literature. The structures of

the posteriorcomplex,suchastheWrisbergligament,may

equallygaininimportancewithinreconstructivesurgical

pro-cedures.

ThedetailedspecificfunctionoftheWrisbergligamentis

stillnotfullyunderstood.Anatomicalstudieshavesuggested

thatitisimportantinrelationtotheharmonyofnormal

mobil-ity ofthe lateral meniscus and lateral femoralcondyle.8–11

Thus,itwouldalsocontributeindirectlytowardthehealthof

thelateralcompartmentofthekneejoint.12

Inourstudy,theWrisbergligamentwasfoundin91.6%of

thekneesevaluated.Inanatomicalstudiesintheliterature,

itsincidencemayrangefrom35%to76%.9,13–16_It_is_possible

thatwefoundtheWrisbergligamentinagreaterpercentage

ofspecimensthanwasseeninotherstudiesbecauseour

dis-sectionwasdoneinaverydetailedmanner,usingascalpel

withaNo.11 blade,withisolationofthestructuresalways

startingfromtheposteriorcornuofthelateralmeniscus.

Choetal.3_and_Watanabe_et_al.17 _identified_the_Wrisberg

ligamentin66%and93%ofthemagneticresonanceimages

evaluated, respectively. These percentages would probably

havebeenevenhigherifequipmentofgreaterresolutionhad

beenused.

In68%ofthekneesofoursample,theinsertionofthe

Wris-bergligamentwasproximaltothemedialintercondylarridge.

However,accordingtoGupteetal.,4_and_also_Yamamoto_and

Hirohata,13_the_Wrisberg_ligament_was_always_in_a_proximal

locationinrelationtothemedialintercondylarridge.

Inourevaluation,themeanareaofinsertionofthe

Wris-berg ligament was 20.46±6.12mm2 _and _the _mean _area _of

insertionofthePCLwas87.80±28.21mm2.Themeanareasof

(4)

r

e

v

b

r

a

s

o

r

t

o

p

.

2

0

1

3;

4

8(5)

:412–416

415

Column1 Column2 Column3 Column5 Column6 Column7 Column8 Column9 Column10 Column11 Column12 Column13

Area(cm2₎ _Greatest

diameter (mm)

Distanceto PMband (mm)

Distanceto ALband (mm)

Distanceto PCLcenter (mm)

Distanceto posterior cart.(mm)

Distanceto distalcart. (mm)

W/PM ratio(% area)

W/AL ratio(% area)

W/PCL ratio(% area)

2 D 21.50 5.20 9.33 14.60 13.16 4.48 9.00 39.95 28.75 16.72

3 E 17.93 5.86 9.40 14.98 10.86 5.23 11.64 22.43 47.17 15.20

4 E 24.38 7.21 7.23 11.48 9.23 9.09 10.40 91.35 85.21 44.09

5 E 22.13 7.55 5.91 10.21 8.66 8.72 13.84 55.39 46.14 25.17

6 E 19.60 5.93 9.46 14.53 11.88 5.74 12.70 56.55 51.93 27.07

7 D 16.15 4.75 7.41 13.87 10.34 4.97 4.75 55.54 54.76 27.57

8 D 22.24 5.26 7.52 14.77 11.89 7.27 8.20 77.22 47.30 29.33

9 E 24.07 5.02 11.82 18.63 14.62 6.72 13.28 41.50 26.74 16.26

10 D 21.16 6.44 7.94 11.89 9.74 7.30 7.91 60.32 51.67 27.83

11 D 37.89 8.31 12.26 17.88 15.32 7.19 13.28 73.34 60.25 33.08

12 D 15.84 4.57 6.86 11.10 8.75 6.79 7.50 67.35 62.91 32.53

13 D 18.47 5.85 9.94 12.15 10.57 6.47 7.09 44.68 37.31 20.33

14 D 25.98 7.53 9.56 16.87 13.73 5.19 11.63 75.15 36.19 24.43

15 E 26.37 6.29 11.80 18.49 14.47 4.10 13.75 68.91 63.01 32.91

17 E 12.44 4.96 6.77 12.44 10.14 7.94 10.42 38.67 28.96 16.56

18 E 29.27 8.87 9.51 16.35 13.28 11.58 12.16 51.14 77.62 30.83

19 E 14.93 4.80 12.10 12.23 11.78 6.99 11.18 70.89 34.67 23.28

20 E 13.90 4.60 12.74 19.81 16.48 5.50 12.11 23.97 28.96 13.11

21 D 18.02 4.83 11.47 10.21 9.64 11.29 12.06 64.36 43.95 26.12

22 D 21.58 9.40 7.52 13.89 10.70 5.95 3.50 86.32 89.92 44.04

23 E 13.37 4.67 8.02 15.19 11.60 7.46 8.52 38.20 44.57 20.57

24 E 12.91 3.90 6.67 10.95 8.71 9.12 8.61 19.86 19.27 9.78

Mean 20.46 5.99 9.15 14.18 11.64 7.05 10.16 55.59 48.51 25.31

(5)

416

rev bras ortop.2013;48(5):412–416

respectively, 47.13±19.14 and 40.67±16.19mm2_. _Thus, _the

meanareaoftheWrisbergligament correspondedto23.3%

oftheareaofthePCL,43.41%oftheareaoftheanterolateral

bandand50.3%oftheareaoftheposteromedialband.

AccordingtoTakahashi etal.,16 _the _mean_area _of

inser-tion ofthe Wrisberg(W)ligament was39.4±13.7mm2 _and

ofthePCL,122.6±50.1mm2_. _The_mean_area _of_insertion_of

the anterolateral(AL)band was58.0±25.4mm2 _and _of_the

posteromedial(PM)band,64.6±24.7mm2_._According_to_these

authors,theW/PCL,W/ALandW/PMarearatioswere,

respec-tively,32.13%,67.93%and60.99%.

The areas obtained in our study were smaller possibly

becauseinadditiontothelikelysexandethnicity-related

vari-ationsamongthesamplesstudied,weexclusivelydelimited

the bonesitesforfemoralinsertion ofthe ligaments,with

carefuldissection,withoutincludingthefibrousexpansions

thatareinsertedonthe peripheryofthebonesitesforthe

insertions.

Inourstudy, likeinthe study byTakahashi etal.,16 _we

foundahighstandarddeviationforthemeanareaofinsertion

oftheWrisbergligamentinthefemur(29.91%and34.77%of

thetotalarea,respectively).Thisprobablydemonstratesthat

therewere considerabledifferencesbetween theindividual

measurementswithinthesample.

Ourstudyhassomelimitations:thenumberofknees

stud-iedmight beconsidered small, giventhe greatanatomical

variationencounteredandalsotheimpossibilityofachieving

three-dimensionalviewingoftheinsertionofthe Wrisberg

ligamentbymeansofadigitalcamera.

Conclusion

Inconclusion,ourfindingssuggestthattheWrisbergligament

isafrequentlyoccurringstructureinkneesandthat,because

itrepresentsanaverageof23.3%oftheareaofinsertionofthe

PCL,itoughttocontributetowardtheposteriorstabilityofthe

knee.

Futurestudiesonselectiveligamentsectioningand

biome-chanicaltestsmaybeabletodeterminewhatthespecificrole

ofthisligamentis,inrelationtoposteriorstabilizationofthe

joint.Meanwhile,everyeffortshouldbemadetoward

preser-vingtheWrisbergligamentinreconstructionsofthePCL.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.PoytonAR,JavadpourSM,FineganPJ,O’BrienM.The meniscofemoralligamentsoftheknee.JBoneSurgBr. 1997;79:327–30.

2.WanACT,FelleP.Themenisco-femoralligaments.ClinAnat. 1995;8:323–6.

3.ChoJM,SuhJS,NaJB,ChoJH,KimY,YooWK,etal.Variations inmeniscofemoralligamentsatanatomicalstydyandMR imaging.SkeletalRadiol.1999;28:189–95.

4.GupteCM,BullAM,ThomasRD,AmisAA.Areviewofthe functionandbiomechanicsofthemeniscofemoralligaments. Arthroscopy.2003;19:161–71.

5.MatavaMJ,EllisE,GruberB.Surgicaltreatmentofposterior cruciateligamenttears:anevolvingeechnique.JAmAcad OrthopSurg.2009;17:435–46.

6.GupteCM,SmithA,McDermottID,BullAM,ThomasRD, AmisAA.Meniscofemoralligamentsrevisited.Anatomical study,agecorrelation,andclinicalimplications.JBoneJoint SurgBr.2002;84:846–51.

7.ChoS,KoS,WooJK.Meniscus-stabilizingfunctionofthe meniscofemoralligament:experimentalstudyofpigknee joints.Arthroscopy.2006;22:872–7.

8.MoranCJ,PoyntonAR,MoranR,O’BrienM.Analysisof meniscofemoralligamenttensionduringkneemotion. Arthroscopy.2006;22:362–6.

9.HellerL,LangmanJ.Themenisco-femoralligamentsofthe humanknee.JBoneJointSurgBr.1964;46:307–13.

10.LastRJ.Someanatomicaldetailsofthekneejoint.JBoneJoint SurgBr.1948;30:683–8.

11.CandiolloL,GauteroG.Morphologieetfonctiondes

ligamentsménisco-femorauxdel’articulationdegenouchez l’homme.ActaAnat.1959;38:304–23.

12.PoyntonA,MoranCJ,MoranR,O’BrienM.The

meniscofemoralligamentsinfluencelateralmeniscalmotion atthehumankneejoint.Arthroscopy.2011;27:365–71.

13.YamamotoM,HirohataK.Anatomicalstudyonthe meniscofemoralligamentsoftheknee.KobeJMedSci. 1991;37:209–26.

14.KohnD,MorenoB.Meniscusinsertionanatomyasabasisfor meniscusreplacement:amorphologicalcadavericstudy. Arthroscopy.1995;11:96–103.

15.RamosLA,deCarvalhoRT,CohenM,AbdallaRJ.Anatomic relationbetweentheposteriorcruciateligamentandthejoint capsule.Arthroscopy.2008;24:1367–72.

16.TakahashiM,MatsubaraT,DoiM,SuzukiD,NaganoA. Anatomicalstudyofthefemoralandtibialinsertionsofthe anterolateralandposteromedialbundlesofhumanposterior cruciateligament.KneeSurgSportsTraumatolArthrosc. 2006;14:1055–9.