The middle geniculate artery (azygous geniculate) arises from the posterior popliteal artery and pierces the posterior joint capsule to supply the cruciate ligaments, synovial lining of the intercondylar notch, and adjacent fat pad. It is the primary blood supply to both cruciate ligaments.
The middle geniculate artery is divided during posterior knee capsulotomy and in total knee arthroplasty, which does not affect cruciate vascularity in PCL-retaining designs. The ACL receives its blood supply principally from this vessel via synovial branches, explaining why intra-articular ACL reconstruction grafts require revascularisation. It is also the target of geniculate artery embolisation for posterior knee osteoarthritis.
Disruption of middle geniculate artery supply to the cruciate ligaments during posterior capsulotomy, reducing intrinsic cruciate healing capacity and contributing to ACL graft ligamentisation delay.
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