Anatomia del compartimento mediale del ginocchio

Body:

ANATOMIA

Le strutture di rinforzo capsulare mediale possono essere divise in tre piani, come descritto da  Warren and Marshall: superficiale, intermedio, e profondo (Figura sottostante).

Lo strato superficiale, o strato I, è composto dalla fascia crurale, strettamente adesa alle fasce del vasto mediale e del sartorio.

Lo strato intermedio, o strato II, è composto dal legamento tibiale collaterale (TCL), il più superficiale del comparto mediale.

Anteriormente, lo strato intermedio si fonde con il superficiale formando il retinacolo patellare mediale. Al di sotto dello strato superficiale possono essere visibili i tendini del gracile e del  semitendinoso.

Lo strato profondo, o strato III, è composto dal legamento capsulare mediale profondo, che si unisce alla capsula.

Posteriormente, lo strato profondo si fonde con l’intermedio attraverso il legamento obliquo posteriore (POL).

La divisione in strati è importante per comprendere l’anatomia, nella pratica di tutti i giorni però viene utilizzato un approccio descrittivo antero-posteriore.

PORZIONE ANTERIORE

Porzione anteriore:

La componente anteriore delle strutture di supporto mediali è composta dai legamenti del retinacolo mediale e dai tendini della zampa d’oca.

Il retinacolo mediale è a sua volta formato dalle componenti mediali patellofemorale, patellomeniscale e patellotibiale (MPFL), la più importante tra queste strutture (fig.4).

Il MPFL origina dal tubercolo tibiale, subito anteriormente e distalmente al tubercolo degli adduttori del femore. Esiste inoltre una componente obliqua che origina dalla porzione possimale del TCL. I legamenti decorrono orizzontalmente e si uniscono al tendine profondo del vasto mediale prima di inserirsi direttamente sulla rotula.

A causa del decorso orizzontale il MPFL è visualizzabile nelle immagini assiali a livello della sua inserzione sul tubercolo. Nelle immagini assiali esso appare bilaminare, la porzione più esterna è la fascia crurale, quella più interna è il MPFL.

La distrazione del MPFL è spesso associata ad edema nella regione di inserzione degli adduttori, o edema ed infarcimento della porzione distale del vasto mediale.

Owing to its horizontal course, the MPFL is best evaluated on axial images at the level of the adductor tubercle. On axial images, the medial retinaculum has a bilaminar appearance with the outer layer consisting of the crural fascia and inner layer composed of the MPFL.

The posterior-most aspect of the MPFL is intimate with the TCL, with some fibers passing over the TCL. Disruption of the MPFL near its femoral attachment is often associated with edema in the region of the adductor tubercle, edema or fluid deep to the vastus medialis muscle, or both findings (Figure 5).

PORZIONE CENTRALE

La componente centrale delle strutture di supporto mediali è composta dal TCL e dal legamento capsulare profondo. Il TCL è appare come una banda con una inserzione femorale e due inserzioni tibiali.

L’inserzione femorale del TCL è subito al disotto della fisi del femore dove si inserisce posteriormente alla zona centrale dell’epicondilo femorale mediale.

L’inserzione prossimale tibiale del TCL è sulla porzione anteriore del tendine del semimenbranoso.

L’inserzione distale tibiale è a circa 6-7 cm dalla linea articolare, profondamente ai tendini della zampa d’oca.

PORZIONE POSTERIORE

E’ localizzata all’angolo postero-mediale del ginocchio, composta dal POL, dal legamento popliteo obliquo, dal tendine del semimembranoso e dal tendine mediale del gastrocnemio.

Il POL a sua volta ha 3 componenti: superficiale, centrale e capsulare.

La sua inserzione femorale prossimale è ampia e localizzata posteriormente al tubercolo degli adduttori. La componente superficiale decorre lungo il margine posteriore del TCL, intersecandosi distalmente con le espansioni tibiali del tendine del seminembranoso.

Il braccio centrale del POL forma la porzione principale del legamento, che rinforza la capsula postero-mediamente ed è strettamente adesso al corno posteriore del menisco mediale.

La componente capsulare si inserisce alla porzione postero-mediale della capsula articolare e si unisce  al tendine del semimembranoso formando parte del del legamento popliteo.

a cura della Dott.ssa Marta Giulia Barelli

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