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Meniscal arrow migration into the popliteal fossa following attempted meniscal repair: a report of two cases
The Knee 9 Ž2002. 69᎐71
Case report
Meniscal arrow migration into the popliteal fossa following attempted meniscal repair: a report of two cases R.C. Hartley a,U , Y.L. Leung b a
Department of Orthopaedics, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, UK b Department of Orthopaedics, Uni¨ ersity Hospital Aintree, Lower Lane, Li¨ erpool L9 7AL, UK Received 14 May 2001; accepted 11 June 2001
Keywords: Meniscal arrow migration; Popliteal fossa
1. Introduction This article describes a previously unreported complication of meniscal repair using arrows. In the two cases the meniscal arrows have migrated from their site of insertion to the popliteal fossa. Meniscal tears can be repaired with meniscal arrows or sutures. Arrows have been reported to have a lower risk of neurovascular complications and are easier to insert w1x. The Biofix absorbable meniscal arrow ŽBIONX Implants Ltd., Tampere, Finland. is T shaped with a barbed shaft and a pointed apex ŽFig. 1.. Three lengths are available to deal with anterior, middle and posterior thirds of the meniscus Ž10, 13 and 16 mm, respectively.. Full reabsorption of the arrow takes 3 years ŽBIONX Implants Ltd., Tampere, Finland.. Over the past few years, case reports of complications have arisen ranging from transient posterior knee pain w3x to subcutaneous migration w2x. The Biofix Meniscal Arrow system has been used in a total of 30 cases in our centre since February 2000. The main indication for insertion of meniscal arrows is peripheral meniscal tears that are likely to heal.
U
Corresponding author.
2. Case reports 2.1. Case 1 A 43-year-old male decorator was transferred to our care from another hospital. He had originally presented with true locking of his left knee. There was no history of trauma attributed to a sporting activity. He underwent diagnostic knee arthroscopy at the referring hospital which revealed a bucket handle tear of the medial meniscus. He was re-examined at our unit and was found to have good quadriceps muscle bulk with no evidence of an effusion. He had a full range of movement in the knee joint. Rotatory testing demonstrated clicking over the medial joint line. A repeat left knee arthroscopy, with the intention to repair the torn medial meniscus, confirmed the presence of a large bucket handle tear of the middle and posterior thirds. Repair of the medial meniscus with two 16-mm Bionx meniscal arrows was carried out and a good fix of the meniscus was achieved. The remainder of the procedure was uneventful and he was subsequently discharged home. The patient was given instructions not to squat for 6 weeks. He was advised to continue with physiotherapy. Two weeks post-operatively he noticed a lump in the medial aspect of his popliteal fossa with associ-
0968-0160r02r$ - see front matter 䊚 2002 Elsevier Science B.V. All rights reserved. PII: S 0 9 6 8 - 0 1 6 0 Ž 0 1 . 0 0 1 2 0 - X
70
R.C. Hartley, Y.L. Leung r The Knee 9 (2002) 69᎐71
Fig. 1. 13-mm meniscal arrow.
ated pain. Close examination revealed the lump to be one of the meniscal arrows. There was no evidence of infection or effusion in the knee joint. The arrow was removed intact under general anaesthetic via an open procedure and the patient made an uneventful recovery. He has since gone back to his work as a decorator without ill effects. 2.2. Case 2 A 27-year-old male sports journalist was referred to us with recurrent instability of his left knee following a football injury. He was unsure of the actual mechanism but recalls that his knee swelled up immediately thus suggesting an acute haemarthrosis. Initial examination revealed quadriceps wasting with no joint line tenderness. The knee demonstrated a good range of movement. Lachman’s test was positive. A subsequent MRI scan of the knee showed no evidence of a meniscal tear and no cruciate ligament rupture. He was commenced on a course of physiotherapy. However, despite intense physiotherapy, the patient continued to be symptomatic. A diagnostic arthroscopy was performed which revealed an anterior cruciate ligament ŽACL. rupture with normal menisci. When the patient came to have his ACL reconstructed he was found to have sustained a bucket handle tear of the posterior horn of his medial meniscus. His ACL was repaired with hamstring graft and the tear in his meniscus was repaired with two 16-mm Bionx meniscal arrows. Again the patient was advised not to squat for 6 weeks but to continue with quadriceps and hamstring exercises. He was followed up at 2 weeks and 3 months. At his 3-month appointment, he complained of pain
and a lump in the lateral aspect of the popliteal fossa. Examination confirmed the presence of a lump in this region. There was no evidence of infection. An ultra-sound scan of this area revealed a 2 = 3 mm acoustic shadow ŽFig. 2.. Five months after the original surgery, he underwent removal of the arrow via an open procedure. The arrow was found to be intact with no evidence of damage. The patient has since made an uneventful recovery and is back playing football.
Fig. 2. Ultrasound scan of meniscal arrow in popliteal fossa.
R.C. Hartley, Y.L. Leung r The Knee 9 (2002) 69᎐71
3. Discussion Subcutaneous migration of meniscal arrows has recently been reported w3x. However, there have been no reports of arrows being found in the popliteal fossa. These cases demonstrate that meniscal arrows can migrate to this region which can cause potential neurovascular complications. Strict adherence to the manufacturer’s guidelines was observed for these cases. The length of arrows used did not exceed that recommended by the manufacturer. The arrows removed were intact. It has been suggested that failure of the arrow head to hold the torn meniscus may have allowed the arrow to migrate w3x. This explanation is likely to be the reason for these cases. Neither of these patients has complained of recurrence of mechanical symptoms attributable to their meniscal pathology. These cases illustrate the need to be aware that arrows can migrate to areas remote from their site of insertion and should be considered in patients who have undergone meniscal repair using arrows. Patients should be warned of this possible complication, which may necessitate removal of the arrows.
71
We recommend that arrows found in the popliteal region be removed as soon as possible.
Note Added in Proof ‘‘Since accepting this paper the Editor has become aware of another report of a similar complication Žref. Iannotti S., Goldberg MJ and Richmond JC. Subcutaneous migration of bioabsorbable meniscal arrows. Am J Knee Surg 2001;14:122᎐124.. However it has been decided to go ahead with publication since the increasing trend towards meniscal repair is likely to mean this problem is seen more frequently and readers should be made aware of it’’. References w1x Albrecht-Olsen P, Kristensen G, Tormala P. Meniscus bucket handle fixation with an absorbable biofix tack: development of a new technique. Knee Surg Sports Traumatol Arthrosc 1993;1:104᎐106. w2x Ganko A, Engebretsen L. Subcutaneous migration of meniscal arrows after failed meniscus repair: a report of two cases. Am J Sports Med 2000;28Ž2.:252᎐253. w3x Whitman TL, Diduch DR. Transient posterior knee pain with the meniscal arrow wabstract x. Arthroscopy 1998;14:762᎐763.
Case report
Meniscal arrow migration into the popliteal fossa following attempted meniscal repair: a report of two cases R.C. Hartley a,U , Y.L. Leung b a
Department of Orthopaedics, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, UK b Department of Orthopaedics, Uni¨ ersity Hospital Aintree, Lower Lane, Li¨ erpool L9 7AL, UK Received 14 May 2001; accepted 11 June 2001
Keywords: Meniscal arrow migration; Popliteal fossa
1. Introduction This article describes a previously unreported complication of meniscal repair using arrows. In the two cases the meniscal arrows have migrated from their site of insertion to the popliteal fossa. Meniscal tears can be repaired with meniscal arrows or sutures. Arrows have been reported to have a lower risk of neurovascular complications and are easier to insert w1x. The Biofix absorbable meniscal arrow ŽBIONX Implants Ltd., Tampere, Finland. is T shaped with a barbed shaft and a pointed apex ŽFig. 1.. Three lengths are available to deal with anterior, middle and posterior thirds of the meniscus Ž10, 13 and 16 mm, respectively.. Full reabsorption of the arrow takes 3 years ŽBIONX Implants Ltd., Tampere, Finland.. Over the past few years, case reports of complications have arisen ranging from transient posterior knee pain w3x to subcutaneous migration w2x. The Biofix Meniscal Arrow system has been used in a total of 30 cases in our centre since February 2000. The main indication for insertion of meniscal arrows is peripheral meniscal tears that are likely to heal.
U
Corresponding author.
2. Case reports 2.1. Case 1 A 43-year-old male decorator was transferred to our care from another hospital. He had originally presented with true locking of his left knee. There was no history of trauma attributed to a sporting activity. He underwent diagnostic knee arthroscopy at the referring hospital which revealed a bucket handle tear of the medial meniscus. He was re-examined at our unit and was found to have good quadriceps muscle bulk with no evidence of an effusion. He had a full range of movement in the knee joint. Rotatory testing demonstrated clicking over the medial joint line. A repeat left knee arthroscopy, with the intention to repair the torn medial meniscus, confirmed the presence of a large bucket handle tear of the middle and posterior thirds. Repair of the medial meniscus with two 16-mm Bionx meniscal arrows was carried out and a good fix of the meniscus was achieved. The remainder of the procedure was uneventful and he was subsequently discharged home. The patient was given instructions not to squat for 6 weeks. He was advised to continue with physiotherapy. Two weeks post-operatively he noticed a lump in the medial aspect of his popliteal fossa with associ-
0968-0160r02r$ - see front matter 䊚 2002 Elsevier Science B.V. All rights reserved. PII: S 0 9 6 8 - 0 1 6 0 Ž 0 1 . 0 0 1 2 0 - X
70
R.C. Hartley, Y.L. Leung r The Knee 9 (2002) 69᎐71
Fig. 1. 13-mm meniscal arrow.
ated pain. Close examination revealed the lump to be one of the meniscal arrows. There was no evidence of infection or effusion in the knee joint. The arrow was removed intact under general anaesthetic via an open procedure and the patient made an uneventful recovery. He has since gone back to his work as a decorator without ill effects. 2.2. Case 2 A 27-year-old male sports journalist was referred to us with recurrent instability of his left knee following a football injury. He was unsure of the actual mechanism but recalls that his knee swelled up immediately thus suggesting an acute haemarthrosis. Initial examination revealed quadriceps wasting with no joint line tenderness. The knee demonstrated a good range of movement. Lachman’s test was positive. A subsequent MRI scan of the knee showed no evidence of a meniscal tear and no cruciate ligament rupture. He was commenced on a course of physiotherapy. However, despite intense physiotherapy, the patient continued to be symptomatic. A diagnostic arthroscopy was performed which revealed an anterior cruciate ligament ŽACL. rupture with normal menisci. When the patient came to have his ACL reconstructed he was found to have sustained a bucket handle tear of the posterior horn of his medial meniscus. His ACL was repaired with hamstring graft and the tear in his meniscus was repaired with two 16-mm Bionx meniscal arrows. Again the patient was advised not to squat for 6 weeks but to continue with quadriceps and hamstring exercises. He was followed up at 2 weeks and 3 months. At his 3-month appointment, he complained of pain
and a lump in the lateral aspect of the popliteal fossa. Examination confirmed the presence of a lump in this region. There was no evidence of infection. An ultra-sound scan of this area revealed a 2 = 3 mm acoustic shadow ŽFig. 2.. Five months after the original surgery, he underwent removal of the arrow via an open procedure. The arrow was found to be intact with no evidence of damage. The patient has since made an uneventful recovery and is back playing football.
Fig. 2. Ultrasound scan of meniscal arrow in popliteal fossa.
R.C. Hartley, Y.L. Leung r The Knee 9 (2002) 69᎐71
3. Discussion Subcutaneous migration of meniscal arrows has recently been reported w3x. However, there have been no reports of arrows being found in the popliteal fossa. These cases demonstrate that meniscal arrows can migrate to this region which can cause potential neurovascular complications. Strict adherence to the manufacturer’s guidelines was observed for these cases. The length of arrows used did not exceed that recommended by the manufacturer. The arrows removed were intact. It has been suggested that failure of the arrow head to hold the torn meniscus may have allowed the arrow to migrate w3x. This explanation is likely to be the reason for these cases. Neither of these patients has complained of recurrence of mechanical symptoms attributable to their meniscal pathology. These cases illustrate the need to be aware that arrows can migrate to areas remote from their site of insertion and should be considered in patients who have undergone meniscal repair using arrows. Patients should be warned of this possible complication, which may necessitate removal of the arrows.
71
We recommend that arrows found in the popliteal region be removed as soon as possible.
Note Added in Proof ‘‘Since accepting this paper the Editor has become aware of another report of a similar complication Žref. Iannotti S., Goldberg MJ and Richmond JC. Subcutaneous migration of bioabsorbable meniscal arrows. Am J Knee Surg 2001;14:122᎐124.. However it has been decided to go ahead with publication since the increasing trend towards meniscal repair is likely to mean this problem is seen more frequently and readers should be made aware of it’’. References w1x Albrecht-Olsen P, Kristensen G, Tormala P. Meniscus bucket handle fixation with an absorbable biofix tack: development of a new technique. Knee Surg Sports Traumatol Arthrosc 1993;1:104᎐106. w2x Ganko A, Engebretsen L. Subcutaneous migration of meniscal arrows after failed meniscus repair: a report of two cases. Am J Sports Med 2000;28Ž2.:252᎐253. w3x Whitman TL, Diduch DR. Transient posterior knee pain with the meniscal arrow wabstract x. Arthroscopy 1998;14:762᎐763.