- Email: [email protected]
Bilaterally painful anomalous insertion of the medial meniscus in a volleyball player with Marfanoid features
Arthroscopy: The Journal of Arthroscopic and Related Surgery 9(2):217-219
Published by Raven Press, Ltd. © 1993 Arthroscopy Association of North America
Case Report
Bilaterally Painful Anomalous Insertion of the Medial Meniscus in a Volleyball Player With Marfanoid Features Mark D. Santi, M.D. and Allen B. Richardson, M.D.
Summary: A female volleyball player with a Marfanoid habitus had bilateral symptomatic anomalous insertions of the medial meniscus. Arthroscopic resection of the anomalous portions of the medial menisci as they attached to the anterior cruciate ligament successfully eliminated her symptoms. Key Words: Medial meniscus--Anomalies--Marfan's syndrome.
Anomalies of the medial meniscus are rare. They include discoid variants (I ,2), complete absence (3), hypoplasia of the anterior horn (4), and anomalous attachment of the posterior horn to the entire femoral condyle (5). One brief description of the anterior horn becoming continuous with the anterior cruciate ligament was noted in the orthopedic literature but no details concerning the case were offered (4). We present a case of bilateral symptomatic anomalous insertions of the anterior horn of the medial meniscus up along the course of the anterior cruciate ligament in a female volleyball player with a Marfanoid habitus.
medial knee pain that did not resolve with 3 weeks of crutch-assisted ambulation and rest. Physical examination revealed an antalgic gait, limited range of motion from 20 to 145° of knee flexion, and a small effusion. No ligamentous instability was noted but the patient was tender to palpation along the anterior medial knee joint, and a McMurray's maneuver exacerbated the pain. A tentative diagnosis of torn anterior medial meniscus was made. It was noted at the time of physical examination that the patient had disproportionately long arms, fingers, and toes. There was hyperlaxity at the wrist and elbow joints, mild pectus excavatum, and no evidence of scoliosis. Her vision was excellent and there were no cardiac abnormalities noted. The patient's father was described as "tall and lanky", but there was no known family history of Marfan's syndrome. She had been told previously that she might have Marfan's syndrome, but at the time of our examination desired no further work-up. At arthroscopy, the anterior horn of the medial meniscus was seen to partially attach to and run up along the entire course of the anterior cruciate ligament (Fig. 1). There were no tears in the medial meniscus and no other pathology was noted in the knee. The anomalous portion of the medial meniscus was trimmed and contoured to resemble a normal meniscus. Following this resection, no instability or hypermobility of the medial meniscus was present. The patient made a rapid recovery and returned to volleyball without any pain or instability in the knee.
CASE REPORT A 6' 3" tall, 15-year-old female volleyball player, while at a volleyball camp, first began experiencing right medial knee pain following an episode of "giving w a y " while landing on an extended knee. The pain slowly resolved but the knee was intermittently uncomfortable with vigorous activity. Eight months after volleyball camp, the patient once again experienced a buckling episode of the knee while attempting to stand on a surf board. This time, the patient experienced persistent anterior From the Division of Orthopedic Surgery, University of Hawaii, Honolulu, Hawaii, U.S.A. Address correspondence and reprint requests to Mark D. Santi, M.D., Division of Orthopaedics, John A. Burns School of Medicine, University of Hawaii, 1356 Lusitana Street, Room 614, Honolulu, Hawaii 96813, U.S.A.
217
218
M. D. S A N T I A N D A. B. R I C H A R D S O N
1A,B
ANOMALOUS / MEDIAL MENISCUS iNSERTION
,/ HO(~K
FIG. 1. A and B: The picture at arthroscopy and a diagrammatic representation of the right knee showing the anomalous insertion of the anterior horn of the medial meniscus. Note that the anterior horn actually attaches to and runs along the course of the anterior cruciate ligament but is still a discrete structure.
Four months after the arthroscopy of her right knee, the patient began experiencing anterior medial knee pain in the opposite knee. She experienced no episodes of "giving way", but continued to have significant pain despite 6 weeks of rest. Physical examination once again revealed tenderness to palpation along the anterior medial knee joint and exacerbation of pain with a McMurray's maneuver. A minimal effusion was noted and no ligamentous instability was present. Arthroscopy revealed the same anomalous insertion of the anterior medial meniscus onto the entire course of the anterior cruciate ligament (Fig. 2). Resection of the anomalous portion of the medial meniscus was
again performed (Fig. 3) and the patient returned rapidly to full activity without pain. At the most recent follow-up, now 16 months following the original arthroscopy, the patient continues to play competitive volleyball without pain or "giving w a y " of either knee. DISCUSSION Marfan's syndrome has been well known to have numerous musculoskeletal manifestations: arachnodactyly, pectus excavatum, dolichostenomelia (increased length of limbs with respect to trunk), joint laxity, and scoliosis (6,7"). However, to our
2A,B
• L A Y EEEMORAL S A L CONDYLE
/ " / / " ~" ANOMALOUS MEDIALMENISOUS INSERTION
/-
\ ANTERIOR GRUC~ATE L~GAMENT
FIG. 2. A and B: The picture at arthroscopy and a diagrammatic representation of the left knee showing the same anomalous insertion of the anterior medial meniscus. Arthroscopy, Vol. 9, No. 2, 1993
A N O M A L O U S I N S E R T I O N OF MEDICAL M E N I S C U S
219
3A,B
RESECTED ANOMALOUS MED}ALMENISCUS
~
ANTERIOR CRUCIATE LtGAMENT
FIG. 3. A and B: The picture at arthroscopy and a diagrammatic representation of the left knee after the anomalous insertion has been resected. Note that the anterior cruciate ligament had been partially covered by the anomalous meniscus.
knowledge, no association with knee abnormalities or specific meniscal anomalies has been reported. In our case, although the patient had a very characteristic Marfanoid habitus, the diagnosis of Marfan's syndrome was not been made, since the patient chose not to undergo thorough ophthalmotogic or cardiac evaluation to rule out lens dislocation, or aortic enlargement or mitral valve abnormalities, respectively. Additionally, there was no confirmed family history of Marfan's disease. However, given that the proposed pathogenesis of Marfan's syndrome involves collagen synthesis (6,7), it is not incomprehensible that anomalies of knee cartilage may be associated with the syndrome. The one previous description of an anomalous insertion of the anterior medial meniscus onto the anterior cruciate ligament contained no details of symptoms (if any), treatment, or body habitus (4). It is not known whether our patient's Marfanoid features are related to her meniscal anomalies, but it is clear that the anomalous insertion of her anterior medial meniscus caused recurrent episodes of instability and anterior medial knee pain. The feeling of instability was likely due to the anomalous bundle of anterior meniscus subluxing underneath the fem-
oral condyle during knee flexion, and, upon rapid knee extension (landing on an extended knee or quickly attempting to stand on a surf board), the condyle rolled back over the bundle. The recurrent pain was likely due to resultant inflammation and impingement of the condyle onto this anomalous portion of anterior horn. Given this condition, we believed that arthroscopic resection of the anomalous portion of the anterior medial meniscus was indicated, and, thus far, this treatment has proven successful in our patient. REFERENCES 1. Dickason JM, Del Pizzo W, Blazina MF, et al. A series of ten discoid medial menisci. Ctin Orthop 1982;168:75-9. 2. Hough AJ Jr., Webber RJ. Pathology of the meniscus. Clin Orthop 1990;252:32-40. 3. Dandy DJ. Arthroscopy of the knee. Philadelphia: Lea and Febiger, 1984. 4. Johnson LL. Arthroscopic surgery: Principles and practice. St. Louis: C.V. Mosby, 1986:493-4. 5. Riachi E, Pharles A. An unusual deformity of the medial semilunar cartilage. J Bone Joint Surg 1963;45B: 146-7. 6. Fialkow PJ. Marfan syndrome. In: Petersdoff RG, Adams RD, Braunwald E, eds. Harrison's principles on internal medicine. 10th ed. New York: McGraw-Hill, 1983:574-7. 7. Pyeritz R, McKusick VA. The Marfan syndrome: Diagnosis and management. N Engl J Med 1979;300:772-7.
Arthroscopy, Vol. 9, No. 2, 1993
Published by Raven Press, Ltd. © 1993 Arthroscopy Association of North America
Case Report
Bilaterally Painful Anomalous Insertion of the Medial Meniscus in a Volleyball Player With Marfanoid Features Mark D. Santi, M.D. and Allen B. Richardson, M.D.
Summary: A female volleyball player with a Marfanoid habitus had bilateral symptomatic anomalous insertions of the medial meniscus. Arthroscopic resection of the anomalous portions of the medial menisci as they attached to the anterior cruciate ligament successfully eliminated her symptoms. Key Words: Medial meniscus--Anomalies--Marfan's syndrome.
Anomalies of the medial meniscus are rare. They include discoid variants (I ,2), complete absence (3), hypoplasia of the anterior horn (4), and anomalous attachment of the posterior horn to the entire femoral condyle (5). One brief description of the anterior horn becoming continuous with the anterior cruciate ligament was noted in the orthopedic literature but no details concerning the case were offered (4). We present a case of bilateral symptomatic anomalous insertions of the anterior horn of the medial meniscus up along the course of the anterior cruciate ligament in a female volleyball player with a Marfanoid habitus.
medial knee pain that did not resolve with 3 weeks of crutch-assisted ambulation and rest. Physical examination revealed an antalgic gait, limited range of motion from 20 to 145° of knee flexion, and a small effusion. No ligamentous instability was noted but the patient was tender to palpation along the anterior medial knee joint, and a McMurray's maneuver exacerbated the pain. A tentative diagnosis of torn anterior medial meniscus was made. It was noted at the time of physical examination that the patient had disproportionately long arms, fingers, and toes. There was hyperlaxity at the wrist and elbow joints, mild pectus excavatum, and no evidence of scoliosis. Her vision was excellent and there were no cardiac abnormalities noted. The patient's father was described as "tall and lanky", but there was no known family history of Marfan's syndrome. She had been told previously that she might have Marfan's syndrome, but at the time of our examination desired no further work-up. At arthroscopy, the anterior horn of the medial meniscus was seen to partially attach to and run up along the entire course of the anterior cruciate ligament (Fig. 1). There were no tears in the medial meniscus and no other pathology was noted in the knee. The anomalous portion of the medial meniscus was trimmed and contoured to resemble a normal meniscus. Following this resection, no instability or hypermobility of the medial meniscus was present. The patient made a rapid recovery and returned to volleyball without any pain or instability in the knee.
CASE REPORT A 6' 3" tall, 15-year-old female volleyball player, while at a volleyball camp, first began experiencing right medial knee pain following an episode of "giving w a y " while landing on an extended knee. The pain slowly resolved but the knee was intermittently uncomfortable with vigorous activity. Eight months after volleyball camp, the patient once again experienced a buckling episode of the knee while attempting to stand on a surf board. This time, the patient experienced persistent anterior From the Division of Orthopedic Surgery, University of Hawaii, Honolulu, Hawaii, U.S.A. Address correspondence and reprint requests to Mark D. Santi, M.D., Division of Orthopaedics, John A. Burns School of Medicine, University of Hawaii, 1356 Lusitana Street, Room 614, Honolulu, Hawaii 96813, U.S.A.
217
218
M. D. S A N T I A N D A. B. R I C H A R D S O N
1A,B
ANOMALOUS / MEDIAL MENISCUS iNSERTION
,/ HO(~K
FIG. 1. A and B: The picture at arthroscopy and a diagrammatic representation of the right knee showing the anomalous insertion of the anterior horn of the medial meniscus. Note that the anterior horn actually attaches to and runs along the course of the anterior cruciate ligament but is still a discrete structure.
Four months after the arthroscopy of her right knee, the patient began experiencing anterior medial knee pain in the opposite knee. She experienced no episodes of "giving way", but continued to have significant pain despite 6 weeks of rest. Physical examination once again revealed tenderness to palpation along the anterior medial knee joint and exacerbation of pain with a McMurray's maneuver. A minimal effusion was noted and no ligamentous instability was present. Arthroscopy revealed the same anomalous insertion of the anterior medial meniscus onto the entire course of the anterior cruciate ligament (Fig. 2). Resection of the anomalous portion of the medial meniscus was
again performed (Fig. 3) and the patient returned rapidly to full activity without pain. At the most recent follow-up, now 16 months following the original arthroscopy, the patient continues to play competitive volleyball without pain or "giving w a y " of either knee. DISCUSSION Marfan's syndrome has been well known to have numerous musculoskeletal manifestations: arachnodactyly, pectus excavatum, dolichostenomelia (increased length of limbs with respect to trunk), joint laxity, and scoliosis (6,7"). However, to our
2A,B
• L A Y EEEMORAL S A L CONDYLE
/ " / / " ~" ANOMALOUS MEDIALMENISOUS INSERTION
/-
\ ANTERIOR GRUC~ATE L~GAMENT
FIG. 2. A and B: The picture at arthroscopy and a diagrammatic representation of the left knee showing the same anomalous insertion of the anterior medial meniscus. Arthroscopy, Vol. 9, No. 2, 1993
A N O M A L O U S I N S E R T I O N OF MEDICAL M E N I S C U S
219
3A,B
RESECTED ANOMALOUS MED}ALMENISCUS
~
ANTERIOR CRUCIATE LtGAMENT
FIG. 3. A and B: The picture at arthroscopy and a diagrammatic representation of the left knee after the anomalous insertion has been resected. Note that the anterior cruciate ligament had been partially covered by the anomalous meniscus.
knowledge, no association with knee abnormalities or specific meniscal anomalies has been reported. In our case, although the patient had a very characteristic Marfanoid habitus, the diagnosis of Marfan's syndrome was not been made, since the patient chose not to undergo thorough ophthalmotogic or cardiac evaluation to rule out lens dislocation, or aortic enlargement or mitral valve abnormalities, respectively. Additionally, there was no confirmed family history of Marfan's disease. However, given that the proposed pathogenesis of Marfan's syndrome involves collagen synthesis (6,7), it is not incomprehensible that anomalies of knee cartilage may be associated with the syndrome. The one previous description of an anomalous insertion of the anterior medial meniscus onto the anterior cruciate ligament contained no details of symptoms (if any), treatment, or body habitus (4). It is not known whether our patient's Marfanoid features are related to her meniscal anomalies, but it is clear that the anomalous insertion of her anterior medial meniscus caused recurrent episodes of instability and anterior medial knee pain. The feeling of instability was likely due to the anomalous bundle of anterior meniscus subluxing underneath the fem-
oral condyle during knee flexion, and, upon rapid knee extension (landing on an extended knee or quickly attempting to stand on a surf board), the condyle rolled back over the bundle. The recurrent pain was likely due to resultant inflammation and impingement of the condyle onto this anomalous portion of anterior horn. Given this condition, we believed that arthroscopic resection of the anomalous portion of the anterior medial meniscus was indicated, and, thus far, this treatment has proven successful in our patient. REFERENCES 1. Dickason JM, Del Pizzo W, Blazina MF, et al. A series of ten discoid medial menisci. Ctin Orthop 1982;168:75-9. 2. Hough AJ Jr., Webber RJ. Pathology of the meniscus. Clin Orthop 1990;252:32-40. 3. Dandy DJ. Arthroscopy of the knee. Philadelphia: Lea and Febiger, 1984. 4. Johnson LL. Arthroscopic surgery: Principles and practice. St. Louis: C.V. Mosby, 1986:493-4. 5. Riachi E, Pharles A. An unusual deformity of the medial semilunar cartilage. J Bone Joint Surg 1963;45B: 146-7. 6. Fialkow PJ. Marfan syndrome. In: Petersdoff RG, Adams RD, Braunwald E, eds. Harrison's principles on internal medicine. 10th ed. New York: McGraw-Hill, 1983:574-7. 7. Pyeritz R, McKusick VA. The Marfan syndrome: Diagnosis and management. N Engl J Med 1979;300:772-7.
Arthroscopy, Vol. 9, No. 2, 1993