0:00

So here I'm showing you in an image as well

0:03

as listed the components, the main components,

0:07

not the only components of the anterior portion,

0:11

the middle portion, and the posterior portion

0:14

of the medial supporting structures.

0:16

And you can see by the brackets color coordinated to

0:19

what the text here

0:21

that perhaps the most narrow segment is the middle segment

0:25

with a wider anterior portion and a wider posterior portion.

0:30

So let's begin our discussion talking about the anterior

0:35

portion of the medial supporting structures.

0:39

And here we deal mainly

0:41

with the medial RET macular ligaments to,

0:44

to talk about these ligaments.

0:46

Just to, uh, remind you in a review,

0:49

there are re macular ligaments on the medial

0:52

and lateral aspect involving the the re re reac.

0:57

And there are three medially and three laterally.

1:00

Most famous of the medial ligaments is the medial

1:04

patello femoral ligament.

1:06

It's labeled MPFL.

1:08

In the, uh, picture on your right,

1:11

this is an important supporting structure

1:14

providing medial stabilizing, uh, effects to the patella.

1:19

And we'll be talking in detail about it.

1:22

There is also a medial patella meniscal ligament,

1:27

which is abbreviated mp uh, ml in the picture.

1:32

And this is a, a, a ligament

1:34

that extends from the patella obliquely downward attaching

1:38

to the anterior horn of the medial meniscus.

1:41

The third of these is the medial patella tibial ligament,

1:45

abbreviated MPTL.

1:48

It too is obliquely oriented, more vertical

1:51

as you can see in the picture,

1:53

and it attaches to the anterior surface

1:55

of the medial tibial plateau.

1:58

So although all of these are important, these three,

2:02

the medial patello femoral ligament is the main stabilizer.

2:07

So let's look at it in a little more detail.

2:11

The femoral attachment shown in the blue circle at the top

2:16

on the right is located about 10 millimeters proximal

2:20

and nine millimeters posterior to one of those landmarks,

2:24

the medial epicondyle and slightly anterior

2:27

and distal to the adductor tubercle.

2:31

The fibers of the medial patella femoral ligament attached

2:34

to the distal border of the tendon of the vast

2:38

medias ocus muscle.

2:39

And you can see that very, very nicely in these pictures.

2:43

And then more recently described is an additional area

2:47

of fibers that attach to the distal portion

2:51

of the quadriceps tendon.

2:52

Not well shown in this, these particular images.

2:57

Now, what's interesting, and something I learned lately,

3:00

and I wish I had learned it earlier,

3:02

when you look at the footprints

3:04

of the medial patello femoral ligament

3:07

and the other two patello, uh, uh, ligaments

3:11

that we talked about, you can see that they are located

3:15

anter to the surface

3:16

of the articular cartilage on the patella.

3:20

So if you have a problem

3:21

with the medial supporting structures involving these reac

3:25

ligaments, you can get avulsions,

3:28

small avulsions without affecting the osteochondral surface.

3:32

Whereas in other cases,

3:35

you may see a more extensive abnormality with evulsion

3:39

of portions of the medial patella femoral ligament

3:42

with an osteochondral injury.

3:45

Obviously, when we see lateral dislocations of the patella,

3:48

and you'll learn more about that later today, we look

3:52

for the extent of damage in the area of the medial aspect

3:56

of the patella.

3:58

Now, one of our visiting scholars from Turkey did a

4:01

beautiful study years ago looking at the anatomy in detail

4:05

of these reac ligaments,

4:07

particularly the medial patello femoral ligament.

4:11

And as you can see on the images on your right, in a drawing

4:15

and also on Mr images, the fibers

4:18

of this particular ligament attached to

4:21

or may pass slightly over the superficial part

4:25

of the medial collateral ligament.

4:27

And that is the tibial collateral ligament.

4:30

You can see that nicely with the MPFL shown

4:33

by the small arrows

4:35

and the large arrows indicating the tibial

4:38

collateral ligament.

4:40

Now compare that to the abnormal

4:42

situation shown on the left.

4:44

This is subtle, but it is significant.

4:46

You'll note here that there is an injury characterized

4:50

by some edema,

4:52

and that is an indi uh, injury at the femoral attachment

4:56

of the medial patello femoral ligament.

4:59

And one of the findings I've seen associated with this,

5:02

and it's shown in this example,

5:04

is rather than the tibial collateral ligament looking like a

5:08

vertical structure of low signal, you can see

5:11

that the upper portion tilts outward

5:16

as if in fact that ligament has pulled it a little bit

5:19

away from the bone.

5:21

That can be a very helpful characteristic of an injury,

5:25

a subtle injury

5:26

of the medial patello femoral ligament at

5:29

its femoral attachment.

5:31

Here's another example again

5:33

with the small arrows indicating the MPFL,

5:36

the large arrows indicating the tibial collateral ligament.

5:41

Here are the fibers

5:42

of the medial patello femoral ligament are disrupted just

5:46

before their attachment to the tibial collateral ligament.

5:50

And once again, you can see the associated edema located

5:55

right next to the medial

5:57

Epicondyle.

5:58

And this is related to this particular injury.

6:01

In this case, the alignment

6:03

and appearance of the tibial collateral ligament is normal

6:07

and doesn't point outward as in the last case.

6:11

Now, also involving the anterior third

6:13

of the medial supporting structures, we deal with the pests

6:17

and serous tendons.

6:19

These are the attachments of the sarus bacillus

6:23

and semi tendinosis.

6:24

And if you want a mnemonic, it forms the word sags

6:28

with sartorious above bacillus in the middle

6:31

and semi tendinosis In the lower aspect, these

6:37

uh, three structures look a little bit like this,

6:40

and hence you'll, you'll see in fact the reference

6:43

to the goose foot on these.

6:46

Now, what's also interesting about these structures,

6:49

there is a bursar found deep to them,

6:52

and that particular bursa is of course a pesan serene bursa.

6:58

And you may get fluid collections within it

7:00

as shown in this example.

7:03

You can see the highlighting

7:04

of the synovium when we use intravenous gadolinium.

7:07

So this is compatible with bursitis.

7:11

I've seen many examples

7:13

where fluid in this bursa is continuous with fluid,

7:16

more posteriorly in the semimembranosus bursa,

7:20

which we will not be talking about today.