J. Anat. (1985), 143, pp.

189-194 With 6 figures Printed in Great Britain

189

Mechanism of locking at the knee joint

K. RAJENDRAN

Department of Anatomy, Faculty of Medicine, National University of Singapore, Kent Ridge, Singapore 0511

(Accepted 27 March 1985)

INTRODUCTION

The diversity of views concerning the mechanism of locking (conjunct rotation, combined rotation) at the knee joint suggests that the primary cause of this phenomenon has not been established beyond dispute. Described by some as a movement necessary for stability, reduction of friction (MacConaill, 1946) and improvement of efficiency (Bamett, 1953), locking has been variously ascribed to bony factors (for, example, unequal length of the femoral condyles), ligamentous factors (tautening of the anterior cruciate ligament) and muscular factors (pull of the quadriceps tendon). The findings of the present study show that bony (articular) factors by themselves are able to influence significantly, if not solely determine, the phenomenon of conjunct rotation during the terminal stages of extension at the knee joint. The experiments carried out took into consideration two established observations on the knee joint: namely, the occurrence of conjunct rotation during the last thirty degrees of extension and its coincidence with the phase of maximal weight bearing at the joint during walking (Barnett, 1953), i.e., when there is a significant load on the joint.
MATERIAL AND METHODS

The knees from formalin-preserved male cadavers with an average age of 70 years study the influence of articular contour on the behaviour of the joints during the terminal stages of extension. They did not show damaged menisci or obvious degenerative changes such as marginal lipping or irregularity of the articular surface. Twenty two lower limbs were detached at the hip joint and the soft tissues immediately above, below and around the knee were cleared. The capsule was divided and trimmed to expose the articular margins of the femoral and tibial condyles. Prior to division of the other ligaments, which would necessarily result in separation of the thigh from the leg, reference points were marked with pins to assist the proper alignment of the femur on the tibia (Fig. 1). With each knee flexed to approximately 30 one pin was inserted close to the articular margin of each condyle, at the point of closest contact with the opposing condyle, i.e., one pin immediately above the other, on each side of the knee (Fig. 1). All the ligaments were then divided and trimmed down close to the bone. The menisci however were left intact. For the first experiment, the leg component of each lower limb was supported vertically in a clamp and the femoral condyles were allowed to rest on the corresponding tibial condyles with the reference pins aligned vertically (i.e., on both sides of the joint). In this position the articulation simulated closely the situation in the intact knee at about 30 of flexion. The inclined thigh was supported at its upper end using an open palm. In this position, the combined weight of the femur and surrounding muscles exerted a load on the joint. From this semiflexed position, the
were used to

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the joint flexed to about 30. Fig. 2. The left leg with the medial tibial condyle sectioned in the sagittal plane to reveal the contour of the articular surface. This is relatively flat posteriorly (P1) but turns upwards as a gentle concavity towards the anterior end (Ai). Fig. 3. The left leg with a portion of the lateral tibial condyle removed through a sagittal section. The posterior part of the articular surface is essentially flat (P2) except for the slope (P.). Anteriorly, there is an obvious downslope (A2). Fig. 4. Anteromedial view of a wooden model of the right knee joint. The femoral component comprises a shaft (S) and medial (C1) and lateral (C2) condyles. The tibial component shows a plateau (P) carrying the medial articular surface with an up slope anteriorly (U) and the lateral articular surface with a down slope (D). Posteriorly, both surfaces are flat. Fig. 5. Medial view of the wooden model in a semiflexed position. The femoral condyles are seated on the flat, posterior parts (Fp) of the tibial condyles. Other labelling as in Figure 4. Fig. 6. The wooden model of the knee in the fully extended position. Note the open hand used for pushing the femoral shaft. The medial femoral condyle (C1) has come to a halt against the up slope (U). The lateral femoral condyle (C 2) has progressed further forwards over the down slope (D) and the shaft is now in a state of medial rotation.

Fig. 1. Medial view of a specimen of the left knee with capsule and ligaments removed, exposing the femoral (F) and tibial (T) condyles. Reference pins (Ri, R2) are in vertical alignment with

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joint was extended by pushing the thigh gently forwards (with the open palm to avoid manually influencing rotation) till it was vertical, i.e. approximately fully extended. Observations were carried out on the behaviour of the femoral condyles throughout the process of extension. The procedure was repeated on all 22 limbs. The second experiment was identical in procedure except that it was carried out
with the medial and lateral menisci removed from all the knees. At the conclusion of the experiment, all the tibial condyles were examined grossly and then sectioned in the sagittal plane about 1 cm from the corresponding intercondylar tubercle in order to examine the articular profiles. All the menisci were examined to study their possible influence on the articular contours of the tibial

condyles.
OBSERVATIONS

In all the knees studied, at about 30 of flexion, the posterior part of each femoral condyle was in articulation with the posterior part of the corresponding tibial condyle. In the first experiment where the menisci were left intact, 18 of the 22 knees showed similar behaviour during extension. As extension commenced, both femoral condyles were observed to roll forwards on the tibial articular surfaces. Soon afterwards, however, the simple forward roll of each condyle was accompanied by varying amounts of backward skid (Hollinshead, 1982). As extension neared completion each condyle behaved differently from the other in a significant way. The medial femoral condyle on reaching the anterior part of the medial tibial condyle and visibly (as viewed from the front) becoming close packed (Barnett, Davies & MacConaill, 1961), before the lateral condyle, had its forward movement effectively cancelled by backward skid. The lateral femoral condyle which did not appear close packed in comparison, continued to roll forwards and medially over the lateral tibial condyle with resultant medial rotation of the femur. This rotation was objectively determined by comparing the displacements of the two femoral reference pins in relation to the corresponding tibial pins. Medial rotation of the femur produced a relatively greater forward displacement of the lateral femoral reference pin. Using this method all the 18 knees showed medial rotation of the femur towards the terminal stages of extension. In the remaining four knees, rotation of the femur was not observed. In the second experiment which was done with the menisci removed, medial rotation of the femur towards the end of extension was observed in all 22 knees. The behaviour of the femoral condyles during extension was essentially similar to that observed in the first experiment with respect to the 18 knees which demonstrated the locking phenomenon.

Tibial articular surfaces and menisci All the medial condyles from the 22 specimens showed a generally concave articular surface (Williams & Warwick, 1980) i.e. mediolaterally as well as anteroposteriorly. The medial meniscus accentuated this concavity at the periphery of the

condyle.
The lateral condyles showed an articular surface that was concave from side to side but different significantly from the medial condyles when examined from behind forwards. The most posterior part showed a down slope (Fig. 3). In the middle it was generally quite flattened but traced further forwards, especially anteromedially, it either remained flattened or, in most specimens, showed a convex down

K. RAJENDRAN 192 slope or camber (Bamett, 1953; Williams & Warwick, 1980) (Fig. 3). This flattening or convexity anteriorly did not appear to be altered significantly by the lateral meniscus which was found to be consistently thin near the anterior horn as compared to its posterior part. In the formalin-preserved and partly dehydrated state, the menisci were generally stiff and immobile. Sagittal sections of the condyles (Figs. 2, 3) confirmed the observations on the articular surfaces with respect to the anteroposterior profile.
DISCUSSION

The medial rotation of the femur on the tibia during the terminal stages of extension at the knee joint has been referred to by different authors as locking (Bamett, 1953),

screwing home (Smillie, 1951), conjunct rotation (Williams & Warwick, 1980) or combined rotation (Tardieu, 1981). In attempting to explain this phenomenon, many theories have been advanced taking into consideration the form of the articular surfaces, the influence of ligaments and the action of muscles on the joint. Textbooks of anatomy attribute the termination of simple extension and its replacement by the locking movement (i.e. extension combined with rotation) to different factors such as the earlier congruence of the lateral half 'of the joint compared to the medial half during extension (Williams & Warwick, 1980), the shorter curves of the lateral femoral condyle becoming exhausted earlier by the hinge motion (Hollinshead, 1982), tautening of the anterior cruciate ligament terminating extension of the lateral condyle of the femur (Last, 1978), and the posterior cruciate ligament holding back the forward movement of the femur (Snell, 1981). Barnett (1953), while emphasising the importance of articular surfaces in producing rotation, attributes the medial rotation of the tibia to the contraction of the quadriceps muscle. Bony factors which have been thought to contribute to locking include the unequal curvilinear lengths of the femoral condyles (Tardieu, 1981), a high bicondylar angle, flattening of the distal articular surfaces of the femoral condyles, and the presence of transverse grooves on these surfaces (Ferguson, 1981). A review of published work shows that in spite of the emphasis on articular factors, relatively little prominence has been given to the part played by the articular contours of the tibial condyles. A general examination of the femur and tibia shows that the femoral condyles both basically present a convex surface suited for a rolling type of movement. The tibial articular surfaces in comparison are relatively flattened, but differ from each other anteriorly, as noted in the present study, the medial condylar surface showing a concave up slope (Fig. 2) and the lateral surface showing either a flattenening or a convexity (Barnett, 1953; Welsh, 1980) (Fig. 3). It appears significant that this difference in contours occurs in the anterior portion of the condyles which articulate during the terminal stages of extension. The exact functions of the menisci in the knee joint are still being elucidated (Hall, 1965) and they are not usually cited as playing any significant role in the locking mechanism. It would appear from the observations in the present study that the menisci, if anything, interfered with conjunct rotation in four of the joints in the first experiment. This may have been due to formalin preservation; relative to the fresh state, the menisci were stiff and immobile and thus likely to prevent the full
influence of the articular contours on one another in the terminal stages of extension when the menisci normally move along with the advancing femoral condyles (Last, 1978; Hall, 1965).

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The articular contours of the femoral and tibial condyles, in the absence of interference from the menisci, may effect locking in the following manner. In the early stages of extension from a semiflexed state, both femoral condyles roll forwards relatively unimpeded (possibly with varying amounts of backward skid) over the posterior parts of the tibial condyles. The forward roll of the femoral condyles brings them to the sloping anterior ends of the tibial condyles. Here, as extension continues, the medial femoral condyle (reaching articular congruity) slips or skids against the up slope of the tibia, especially under the influence of load and lack of friction, thus bringing forward movement to a halt. Conversely, the lateral femoral condyle suffers little or no hindrance from the flattened or downward sloping anterior part of the lateral tibial condyle and is able to continue rolling forwards, so causing medial rotation of the femur. The relative lack of congruity observed between the lateral condyles probably aids forward rolling movement. The thinness of the anterior portion of the lateral meniscus, noted in the present study, may be significant for the following reason, in the event that the meniscus is not mobile enough to keep pace with the forward rolling femoral condyle (as was probably the case with the cadaver knees studied), the resistance it offers would be kept to a minimum. It is therefore not surprising that conjunct rotation could be demonstrated in 18 out of 22 knees in the first experiment in spite of the menisci being relatively fixed. The validity of this explanation of the locking phenomenon on the basis of simple articular contours was tested by incorporating these contours into a wooden model of the knee joint. Figure 4 shows the two components of the model. The femoral component has two identical broad wheels (C1 and C2), representing the convex rolling condyles described earlier, connected by an axle which in turn is rigidly fixed transversely to a rod (R) representing the bone shaft. The tibial component consists of a wooden block carrying two parallel surfaces (the condyles) on top. These surfaces, which receive the 'femoral condyles' are both essentially flat except anteriorly, where one shows a concave up slope (U) to represent the medial tibial condyle and the other a slight down slope (D). All the articular surfaces were sanded smooth to minimise friction. The weight of the femoral component was adequate to exert sufficient load on the model joint. The model was tested out in a manner identical to that of the bony articulations. In the semiflexed state, the two femoral condyles (C1 and C2) were located over the flat posterior aspect of the two tibial condyles with the shaft (R) inclined backwards about 30 from the vertical (Fig. 5). Extension was then simulated by pushing the rod forwards using only the open hand (Fig. 6) so as to avoid! turning it manually. Both 'femoral condyles', as expected, rolled forwards over the two parallel surfaces towards their anterior ends. As extension continued, the 'medial condyle' started to skid backwards against the concave up slope, which provided greater congruity, so that there was no further forward progression. The lateral 'femoral condyle', however, continued to roll forwards and medially over the down slope causing the shaft to rotate medially. It was therefore possible to demonstrate with a model that the phenomenon of locking observed in the cadaver knee joints could result simply from the interaction between the basic contours of the femoral and tibial articular surfaces during the
process of extension, without the need for the restraining influences of ligaments (Shaw, Eng & Murray, 1974) or the action of muscles. The menisci probably did not play any significant role in this phenomenon.

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SUMMARY AND CONCLUSION

The articular contours of the femoral and tibial condyles show certain basic features that in themselves appear sufficient to effect locking at the knee joint during the terminal stages of extension. The essential feature on the femoral condyles is a convex surface adapted for rolling. On the tibia, the contours that chiefly influence rotation are the concave up slope on the anterior portion of the medial condyle that brings the rolling medial femoral condyle to a skidding halt, and the flattening or convex down slope on the anterior part of the lateral tibial condyle that allows the rolling of the lateral femoral condyle to continue further forwards, thus bringing about medial rotation of the shaft. Load on the joint must assist in the locking movement by enhancing the influence of the bony contours.
The author wishes to thank Mr C. C. Koh, Mr P. Gobalakrishnan, Mr Y. K. Han and Mr M. Tajuddin for their technical assistance, and Mrs M. Singh for typing the

manuscript.

REFERENCES

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LAST, R. J. (1978). Anatomy, Regional and Applied. London: Longman Group. MACCONAILL, M. A. (1946). Studies on the mechanics of synovial joints. III. Hinge-joints and the nature of intra-articular displacements. Irish Journal of Medical Science, 620-626. SHAW, J. A., ENG, M. & MURRAY, D. G. (1974). The longitudinal axis of the knee and the role of the cruciate ligaments in controlling transverse rotation. Journal of Bone and Joint Surgery 56A, no. 8. SMILLIE, I. S. (1951). Injuries of the Knee Joint, 2nd ed. Edinburgh: E. & S. Livingstone. SNELL, R. S. (1981). Clinical Anatomy for Medical Students, 2nd ed. Boston, Mass: Little Brown & Co. TARDIEU, C. (1981). Primate Evolutionary Biology (ed. A. R. Chiarelli & R. S. Corruccini). Berlin, Heidelberg: Springer Verlag. WELSH, P. R. (1980). Knee joint structure and function. Clinical Orthopaedics and Related Research 147,
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