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Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: 2. Clinical investigation
Arthroscopy: The Journal of Arthroscopic and Related Surgery 8(4):424421 Published by Raven Press, Ltd. 0 1992 Arthroscopy Association of North America
Anatomy and Pathophysiology of the Popliteal Tendon Area in the Lateral Meniscus: 2. Clinical Investigation Masashi Kimura, M.D., Kenji Shirakura, M.D., Atsushi Hasegawa, Yasukazu Kobayashi, M.D., and Eiichi Udagawa, M.D.
M.D.,
Summary: Treatment of abnormal mobility of the popliteal tendon area of the lateral meniscus is described. Twenty-seven patients who exhibited an abnormally mobile posterior segment with no obvious ruptures in the lateral meniscus were directly examined by us after an average of 4 years and 3 months from the time of the arthroscopic procedure. The main complaints associated with this condition before the surgery were pain and locking during deep knee flexions. The patients were divided into three groups according to surgical method: partial meniscectomy, subtotal meniscectomy, or meniscal repair. The subtotal meniscectomy and repair groups showed significantly higher scores than the partial meniscectomy group. A locking phenomenon recurred in one case of the meniscal repair group. In this case, the meniscofemoral coronary ligament posterior to the popliteal tunnel could not be sutured. Key Words: Follow-up study-Hypermobile lateral meniscus-Popliteal tendonMeniscofemoral coronary ligament-Meniscus suture-Surgery.
Anatomical liteal tendon
and arthroscopic area in the lateral
and 35 had bilateral meniscus injuries. Three hundred sixteen of the 848 with an injured lateral meniscus revealed discoid menisci. One hundred thirty-nine of the 848 showed evidence of trouble near the popliteal tendon area. L-shape ruptures, transverse ruptures, and discoid menisci were not included in the 139 subjects and all had sustained longitudinal-type ruptures. Seventy-two of the 139 showed a peripheral detachment of the posterior segments and 40 revealed a rupture of an external area of the meniscus substance, which seemed to have a blood supply. The remaining 27 menisci revealed no obvious ruptures, but there were cases of abnormal mobility. The 27 subjects consisted of 9 men and 18 women ranging in age from 12 to 52 years (mean: 27.7 years). They were divided into three groups by treatment: partial meniscectomy, subtotal meniscectomy, or meniscal repair. The patients who had received a partial meniscectomy or a subtotal meniscectomy were allowed to walk within the hospital a few days after surgery. The knees of the patients of the meniscal repair group were immobilized in
findings of the popmeniscus were elu-
cidated in Part 1 of this article (1). The purpose of Part II is to report the clinical results of the arthroscopic procedures for the lateral hypermobile meniscus and to describe how to treat an abnormal mobility of this area.
MATERIALS AND METHODS One thousand five hundred ninety-nine patients underwent meniscus surgery in the hospital from April 1978 to February 1989. Eight hundred thirteen patients had lateral meniscus trouble. Of the remaining patients, 751 had medial meniscus injuries From the Department of Orthopaedic Surgery, Gunma Social Welfare Central General Hospital (M.K., A.H., Y.K.), Department of Orthopaedic Surgery, Gunma University School of Medicine (K.S., E.U.), Gunma, Japan. Address correspondence and reprint requests to Masashi Kimura, M.D., Department of Orthopaedic Surgery, Gunma Social Welfare Central General Hospital, 1-7-13 Koun-thou, Maebashi, Gunma, Japan 371.
424
ANATOMY,
PATHOPHYSIOLOGY
long leg casts for 4 weeks. During this period, bearing any weight on the leg was forbidden. We examined all 27 patients directly after the procedures. The follow-up period ranged from 2 years 6 months to 10 years 7 months (mean: 5 years 6 months). The results of the procedures were evaluated by a Lysholm knee scoring scale (2) consisting of eight different categories of evaluation: limp (5 points), support (5 points), locking (15 points), giving way (25 points), pain (25 points), swelling (10 points), stair climbing (10 points), and squatting (5 points). The maximum score was 100 points. The roentogenographic findings were also examined. For statistical analysis, the Wilcoxon’s test and x2 test were used. RESULTS Before surgery, all 27 subjects with a hypermobile meniscus complained of pain that occurred when the knee was flexed and rotated inward or outward such as when arising from a deep sitting posture (sitting Japanese-style on the heels). In addition to this kind of pain, a history of locking was found in all 27 patients. The meniscotibial coronary ligaments of 2 cases were type I and in the other 25, arthroscopy revealed the presence of type II coronary ligaments. One of the two cases with type I showed a general joint laxity (3), and had also experienced patello-
OF POPLITEAL
TENDON AREA: 2
425
femoral trouble. A proximal realignment operation had been performed on this knee before the arthroscopy. Nine partial meniscectomies, 9 subtotal meniscectomies, and 9 meniscal repairs were performed on the 27 patients, respectively. After the surgery, locking recurred in one of the nine repaired cases in which the meniscofemoral coronary ligament posterior to the popliteal tunnel could not be sutured (Fig. 1A and B). In the other cases in the repaired groups, the locking phenomenon never occurred after the procedures. The average scores of the three groups were 78.3 ? 13.5 in the nine partial meniscectomy patients, 94.0 ? 3.9 in the nine patients receiving a subtotal meniscectomy, and 95.3 I~I2.8 in the nine patients in the meniscal repair group. There was no significant difference between the subtotal meniscectomy group and the meniscal repair group, although the partial meniscectomy group showed significantly lower scores (p < 0.05) than those of the subtotal meniscectomy and repair groups (Fig. 2). Roentogenographic findings revealed a mild osteoarthritic change judged grade 1 (4) in only one patient of the subtotal meniscectomy group, and there was no evidence that the degenerative change caused any discomfort of the knee. DISCUSSION The study revealed that the incidences of trouble occurring due to a hypermobility of the lateral me-
FIG. 1. Postoperative arthroscopy of a 2%year-old man who had undergone men&al repair. B: Arthroscopy locking phenomenon 4 months after the meniscal repair.
shows a recurrence of the
Arthroscopy.
Vol. 8. No. 4, 1992
426
M. KIMURA
Partial meniscectomy
78.3
f
13.5
(N =9)
40
60
11
Subtotal meniscectomy
, 0
20 Score
80
100
(Mean + SD)
FIG. 2. Knee functional scores of the three groups. The partial meniscectomy group showed a significantly lower score than the other two groups. Asterisks indicate the significant level (*p 6 0.05).
niscus was 1.7% of the total of 1,634 meniscus surgeries and 3.2% of lateral meniscus surgery. This was not considered to be a very high incidence. The distributions among two types of meniscotibial coronary ligaments in 27 cases were similar to those of the 100 subjects and 10 amputated knees in part 1 of this article (1). That fact does not indicate that anatomical characteristics might be a cause of a symptomatic hypermobile lateral meniscus (Table 1). Analysis of the scores revealed that the outcome was better with a subtotal meniscectomy or a meniscal repair than with a partial meniscectomy. Some patients in the partial meniscectomy group complained of a residual pain and a catching sensation after surgery, and those symptoms made the scores worse than those of the other groups. This was thought to be due to the fact that the meniscus was strongly pulled back by the popliteal muscle when the knee was flexed (5). After a partial meniscectomy, this force was not transmitted to the portion where the residual meniscus and synovial membrane join. The residual meniscus thus imTABLE
1. Distributions
meniscotibial Type Ib
Type II’
Total
A
21 3 2
19 7 25
N = 100d N = 10d N = 27
Hypermobility seemed to appear more frequently in type II, but there were no significant differences among the three groups. a A, Cases with no trouble of the lateral meniscus; B, 10 amputated knees; C, cases with a hypermobile lateral meniscus. b Type I: A meniscotibial coronary ligament covers an entire popliteal tendon beneath the meniscus. c Type II: A popliteal tendon is visible through a defect of the meniscotibial coronary ligament. d Cited from part 1 of this article.
Arthroscopy,
pinged upon the femoral-tibia1 joint causing a persisting pain. For the same reason, locking recurred in one of the cases in the meniscal repair group in which the thick meniscofemoral coronary ligament posterior to the popliteal tunnel could not be sutured . Based on these results, a subtotal meniscectomy and a meniscal repair were considered to be the surgical methods of choice. In the case of the meniscal repair, the rather long postoperative treatment period is a disadvantage, and the risk of a rupture recurrence persists. However, considered from the aspect of meniscal function, preservation of the meniscus is desirable even if this requires a highly invasive procedure. Therefore, meniscal repair should be considered, especially in adolescent patients (6-8). Also, to avoid a recurrence of the locking, the study indicated that when meniscal repair is performed, the meniscofemoral coronary ligament of the posterior segment should be tightly sutured (Fig. 3). When joint laxity is thought to be one of the factors responsible for the hypermobile meniscus, the best therapy may consist of careful follow-up in view of the fact that this condition often improves with time. However, for those cases in which a prior trauma and incomplete healing are thought to be implicated in the meniscus hypermobility, a meniscal repair is indicated.
among type I and type II of coronary ligaments
Group“
:
ET AL.
Vol. 8, No. 4. 1992
FIG. 3. Detachment of a meniscofemoral coronary ligament in a posterior segment of the lateral meniscus. It should be sutured firmly when meniscal repair is indicated.
ANATOMY,
PATHOPHYSIOLOGY
Roentogenographic analysis did not show a difference between the groups. However, many authors (2,5-7) have published articles dealing with osteoarthritic changes In cases _ after meniscectomy. of subtotal meniscectomy, only a short-term rehabilitation program is required, but there is concern about the development of degenerative arthritic changes many years after the operation. Each of the two methods has both advantages and disadvantages and the indication for each should be decided on a case-by-case basis.
CONCLUSIONS 1. The study could not elucidate conclusively that hypermobility of a lateral meniscus would necessarily appear when either a meniscotibial coronary ligament covering an entire popliteal tendon beneath the meniscus (type I), or a popliteal tendon visible through a defect of the meniscotibial coronary ligament (type II), was present.
OF POPLITEAL
TENDON AREA: 2
427
2. A partial meniscectomy is not recommended for the treatment of a hypermobile lateral meniscus. 3. The posterior segment should be sutured firmly to stabilize a hypermobile lateral meniscus. REFERENCES 1. Kimura M, Shirakura K, Hasegawa A, Kohayashi Y, Udagawa E. Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: 1. Arthroscopic and anatomical investigation. Arthroscopy 1992;8:000-000. 2. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injury. Clin Orthop 198_5;198:43-9. 3. Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip. J Bone Join? Surg [Am] 1964;46:40-5. 4. Allen PR. Denham RA, Swan AV. Late degenerative changes after meniscectomy: factors affecting the knee after operation. J Bone Joint Surg [Br] 1984;66:666-71. Kapanddji IA. The physiology of the joints: vol 2. Lower limb, 2nd ed. New York: Churchill Livingstone, 1970:98-9. Tapper EM, Hoover NS. Late results after meniscectomy. J Bone Joint Surg [Am] 1969;51:517-26. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg [Br] 1948;30:664-70. Manzione M, Pizzutillo PD. Peoples AB, Schweizer PA. Meniscectomy in children: a long-term follow-up study. Am J Sports Med 1983;ll:lll~.
Arthroscopy.
Vol. 8. No. 4. 1992
Anatomy and Pathophysiology of the Popliteal Tendon Area in the Lateral Meniscus: 2. Clinical Investigation Masashi Kimura, M.D., Kenji Shirakura, M.D., Atsushi Hasegawa, Yasukazu Kobayashi, M.D., and Eiichi Udagawa, M.D.
M.D.,
Summary: Treatment of abnormal mobility of the popliteal tendon area of the lateral meniscus is described. Twenty-seven patients who exhibited an abnormally mobile posterior segment with no obvious ruptures in the lateral meniscus were directly examined by us after an average of 4 years and 3 months from the time of the arthroscopic procedure. The main complaints associated with this condition before the surgery were pain and locking during deep knee flexions. The patients were divided into three groups according to surgical method: partial meniscectomy, subtotal meniscectomy, or meniscal repair. The subtotal meniscectomy and repair groups showed significantly higher scores than the partial meniscectomy group. A locking phenomenon recurred in one case of the meniscal repair group. In this case, the meniscofemoral coronary ligament posterior to the popliteal tunnel could not be sutured. Key Words: Follow-up study-Hypermobile lateral meniscus-Popliteal tendonMeniscofemoral coronary ligament-Meniscus suture-Surgery.
Anatomical liteal tendon
and arthroscopic area in the lateral
and 35 had bilateral meniscus injuries. Three hundred sixteen of the 848 with an injured lateral meniscus revealed discoid menisci. One hundred thirty-nine of the 848 showed evidence of trouble near the popliteal tendon area. L-shape ruptures, transverse ruptures, and discoid menisci were not included in the 139 subjects and all had sustained longitudinal-type ruptures. Seventy-two of the 139 showed a peripheral detachment of the posterior segments and 40 revealed a rupture of an external area of the meniscus substance, which seemed to have a blood supply. The remaining 27 menisci revealed no obvious ruptures, but there were cases of abnormal mobility. The 27 subjects consisted of 9 men and 18 women ranging in age from 12 to 52 years (mean: 27.7 years). They were divided into three groups by treatment: partial meniscectomy, subtotal meniscectomy, or meniscal repair. The patients who had received a partial meniscectomy or a subtotal meniscectomy were allowed to walk within the hospital a few days after surgery. The knees of the patients of the meniscal repair group were immobilized in
findings of the popmeniscus were elu-
cidated in Part 1 of this article (1). The purpose of Part II is to report the clinical results of the arthroscopic procedures for the lateral hypermobile meniscus and to describe how to treat an abnormal mobility of this area.
MATERIALS AND METHODS One thousand five hundred ninety-nine patients underwent meniscus surgery in the hospital from April 1978 to February 1989. Eight hundred thirteen patients had lateral meniscus trouble. Of the remaining patients, 751 had medial meniscus injuries From the Department of Orthopaedic Surgery, Gunma Social Welfare Central General Hospital (M.K., A.H., Y.K.), Department of Orthopaedic Surgery, Gunma University School of Medicine (K.S., E.U.), Gunma, Japan. Address correspondence and reprint requests to Masashi Kimura, M.D., Department of Orthopaedic Surgery, Gunma Social Welfare Central General Hospital, 1-7-13 Koun-thou, Maebashi, Gunma, Japan 371.
424
ANATOMY,
PATHOPHYSIOLOGY
long leg casts for 4 weeks. During this period, bearing any weight on the leg was forbidden. We examined all 27 patients directly after the procedures. The follow-up period ranged from 2 years 6 months to 10 years 7 months (mean: 5 years 6 months). The results of the procedures were evaluated by a Lysholm knee scoring scale (2) consisting of eight different categories of evaluation: limp (5 points), support (5 points), locking (15 points), giving way (25 points), pain (25 points), swelling (10 points), stair climbing (10 points), and squatting (5 points). The maximum score was 100 points. The roentogenographic findings were also examined. For statistical analysis, the Wilcoxon’s test and x2 test were used. RESULTS Before surgery, all 27 subjects with a hypermobile meniscus complained of pain that occurred when the knee was flexed and rotated inward or outward such as when arising from a deep sitting posture (sitting Japanese-style on the heels). In addition to this kind of pain, a history of locking was found in all 27 patients. The meniscotibial coronary ligaments of 2 cases were type I and in the other 25, arthroscopy revealed the presence of type II coronary ligaments. One of the two cases with type I showed a general joint laxity (3), and had also experienced patello-
OF POPLITEAL
TENDON AREA: 2
425
femoral trouble. A proximal realignment operation had been performed on this knee before the arthroscopy. Nine partial meniscectomies, 9 subtotal meniscectomies, and 9 meniscal repairs were performed on the 27 patients, respectively. After the surgery, locking recurred in one of the nine repaired cases in which the meniscofemoral coronary ligament posterior to the popliteal tunnel could not be sutured (Fig. 1A and B). In the other cases in the repaired groups, the locking phenomenon never occurred after the procedures. The average scores of the three groups were 78.3 ? 13.5 in the nine partial meniscectomy patients, 94.0 ? 3.9 in the nine patients receiving a subtotal meniscectomy, and 95.3 I~I2.8 in the nine patients in the meniscal repair group. There was no significant difference between the subtotal meniscectomy group and the meniscal repair group, although the partial meniscectomy group showed significantly lower scores (p < 0.05) than those of the subtotal meniscectomy and repair groups (Fig. 2). Roentogenographic findings revealed a mild osteoarthritic change judged grade 1 (4) in only one patient of the subtotal meniscectomy group, and there was no evidence that the degenerative change caused any discomfort of the knee. DISCUSSION The study revealed that the incidences of trouble occurring due to a hypermobility of the lateral me-
FIG. 1. Postoperative arthroscopy of a 2%year-old man who had undergone men&al repair. B: Arthroscopy locking phenomenon 4 months after the meniscal repair.
shows a recurrence of the
Arthroscopy.
Vol. 8. No. 4, 1992
426
M. KIMURA
Partial meniscectomy
78.3
f
13.5
(N =9)
40
60
11
Subtotal meniscectomy
, 0
20 Score
80
100
(Mean + SD)
FIG. 2. Knee functional scores of the three groups. The partial meniscectomy group showed a significantly lower score than the other two groups. Asterisks indicate the significant level (*p 6 0.05).
niscus was 1.7% of the total of 1,634 meniscus surgeries and 3.2% of lateral meniscus surgery. This was not considered to be a very high incidence. The distributions among two types of meniscotibial coronary ligaments in 27 cases were similar to those of the 100 subjects and 10 amputated knees in part 1 of this article (1). That fact does not indicate that anatomical characteristics might be a cause of a symptomatic hypermobile lateral meniscus (Table 1). Analysis of the scores revealed that the outcome was better with a subtotal meniscectomy or a meniscal repair than with a partial meniscectomy. Some patients in the partial meniscectomy group complained of a residual pain and a catching sensation after surgery, and those symptoms made the scores worse than those of the other groups. This was thought to be due to the fact that the meniscus was strongly pulled back by the popliteal muscle when the knee was flexed (5). After a partial meniscectomy, this force was not transmitted to the portion where the residual meniscus and synovial membrane join. The residual meniscus thus imTABLE
1. Distributions
meniscotibial Type Ib
Type II’
Total
A
21 3 2
19 7 25
N = 100d N = 10d N = 27
Hypermobility seemed to appear more frequently in type II, but there were no significant differences among the three groups. a A, Cases with no trouble of the lateral meniscus; B, 10 amputated knees; C, cases with a hypermobile lateral meniscus. b Type I: A meniscotibial coronary ligament covers an entire popliteal tendon beneath the meniscus. c Type II: A popliteal tendon is visible through a defect of the meniscotibial coronary ligament. d Cited from part 1 of this article.
Arthroscopy,
pinged upon the femoral-tibia1 joint causing a persisting pain. For the same reason, locking recurred in one of the cases in the meniscal repair group in which the thick meniscofemoral coronary ligament posterior to the popliteal tunnel could not be sutured . Based on these results, a subtotal meniscectomy and a meniscal repair were considered to be the surgical methods of choice. In the case of the meniscal repair, the rather long postoperative treatment period is a disadvantage, and the risk of a rupture recurrence persists. However, considered from the aspect of meniscal function, preservation of the meniscus is desirable even if this requires a highly invasive procedure. Therefore, meniscal repair should be considered, especially in adolescent patients (6-8). Also, to avoid a recurrence of the locking, the study indicated that when meniscal repair is performed, the meniscofemoral coronary ligament of the posterior segment should be tightly sutured (Fig. 3). When joint laxity is thought to be one of the factors responsible for the hypermobile meniscus, the best therapy may consist of careful follow-up in view of the fact that this condition often improves with time. However, for those cases in which a prior trauma and incomplete healing are thought to be implicated in the meniscus hypermobility, a meniscal repair is indicated.
among type I and type II of coronary ligaments
Group“
:
ET AL.
Vol. 8, No. 4. 1992
FIG. 3. Detachment of a meniscofemoral coronary ligament in a posterior segment of the lateral meniscus. It should be sutured firmly when meniscal repair is indicated.
ANATOMY,
PATHOPHYSIOLOGY
Roentogenographic analysis did not show a difference between the groups. However, many authors (2,5-7) have published articles dealing with osteoarthritic changes In cases _ after meniscectomy. of subtotal meniscectomy, only a short-term rehabilitation program is required, but there is concern about the development of degenerative arthritic changes many years after the operation. Each of the two methods has both advantages and disadvantages and the indication for each should be decided on a case-by-case basis.
CONCLUSIONS 1. The study could not elucidate conclusively that hypermobility of a lateral meniscus would necessarily appear when either a meniscotibial coronary ligament covering an entire popliteal tendon beneath the meniscus (type I), or a popliteal tendon visible through a defect of the meniscotibial coronary ligament (type II), was present.
OF POPLITEAL
TENDON AREA: 2
427
2. A partial meniscectomy is not recommended for the treatment of a hypermobile lateral meniscus. 3. The posterior segment should be sutured firmly to stabilize a hypermobile lateral meniscus. REFERENCES 1. Kimura M, Shirakura K, Hasegawa A, Kohayashi Y, Udagawa E. Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: 1. Arthroscopic and anatomical investigation. Arthroscopy 1992;8:000-000. 2. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injury. Clin Orthop 198_5;198:43-9. 3. Carter C, Wilkinson J. Persistent joint laxity and congenital dislocation of the hip. J Bone Join? Surg [Am] 1964;46:40-5. 4. Allen PR. Denham RA, Swan AV. Late degenerative changes after meniscectomy: factors affecting the knee after operation. J Bone Joint Surg [Br] 1984;66:666-71. Kapanddji IA. The physiology of the joints: vol 2. Lower limb, 2nd ed. New York: Churchill Livingstone, 1970:98-9. Tapper EM, Hoover NS. Late results after meniscectomy. J Bone Joint Surg [Am] 1969;51:517-26. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg [Br] 1948;30:664-70. Manzione M, Pizzutillo PD. Peoples AB, Schweizer PA. Meniscectomy in children: a long-term follow-up study. Am J Sports Med 1983;ll:lll~.
Arthroscopy.
Vol. 8. No. 4. 1992