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Discoid Lateral Meniscus in Children. Long-Term Follow-up After Total Meniscectomy*

D. A. RÄBER, M.D., N. F. FRIEDERICH, M.D. and F. HEFTI, M.D., BASEL, SWITZERLAND

Investigation performed at the Department of Pediatric Orthopedics, Children's Hospital, Basel

	Abstract

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We retrospectively reviewed the long-term results of total meniscectomy performed in seventeen knees (fourteen children) to treat a discoid lateral meniscus. The mean duration of follow-up was 19.8 years (range, 12.5 to 26.0 years). On the basis of the rating system of the International Knee Documentation Committee, seven knees were normal (grade A), six were nearly normal (grade B), three were abnormal (grade C), and one was severely abnormal (grade D) at the latest follow-up evaluation. Ten of the seventeen knees had clinical symptoms of osteoarthrosis. Radiographs were available for fifteen of the knees at the latest follow-up evaluation. Eleven of the treated knees could be compared with the uninvolved, contralateral knee. Ten knees had osteoarthrotic changes, such as flattening of the lateral femoral condyle, formation of a ridge along the lateral femoral condyle, and spurring and sclerosis of the tibial plateau. Osteochondritis dissecans in two knees, nine and twenty years after the initial meniscectomy.

	Introduction

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The reported prevalence of discoid meniscus of the knee ranges from 0.4 percent (of 7056 knees)⁴ to 17 percent (no numbers were given in the study)¹². The most common symptoms, which usually occur during childhood and adolescence, are a clunking sound with flexion of the knee, pain, and a decreased range of motion.

In 1957, Kaplan¹⁴ recommended complete excision of a discoid meniscus through two incisions. Since then, several authors^5,8,25 have recommended partial arthroscopic meniscectomy. However, Aichroth et al.³ preferred a total meniscectomy if the discoid lateral meniscus is unstable (Wrisberg-ligament type). The short-term (three-to-seven-year) clinical and radiographic results after partial or total removal of a symptomatic discoid lateral meniscus in children have been favorable^8,9,20. However, studies of the long-term results after partial or total lateral meniscectomy have suggested that there is a high prevalence of osteoarthrotic changes^5,23-25. In addition, lateral instability has been reported after total removal of a discoid lateral meniscus, especially in children¹¹.

Abdon et al.¹ reported that fifty-two (58 percent) of eighty-nine patients had a satisfactory objective result after total removal of a normally shaped meniscus with the use of the Smillie technique²¹. The joint space was narrowed in all knees. According to the grading system of Ahlbäck², as modified by Johnson et al.¹³, thirty-five patients (39 percent) had grade-I osteoarthrosis and eight (9 percent) had grade-II or III osteoarthrosis at a mean of seventeen years after the operation.

We performed the present retrospective study to determine the prevalence of osteoarthrosis after total removal of a symptomatic discoid lateral meniscus in children.

	Materials and Methods

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Between 1961 and 1991, we examined twenty-eight children (thirty-one knees) who had a discoid meniscus. Three patients (three knees) were managed non-operatively, and twenty-five patients (twenty-eight knees) were managed operatively. Eighteen patients (twenty-one knees) had a total meniscectomy, performed between 1961 and 1981. Fourteen of these patients were female and four were male. Eleven right and ten left knees were involved. The mean age at the time of the operation was nine years (range, three to fourteen years). A Smillie incision²¹ was used in seventeen knees, and a lateral parapatellar incision was used in four. The mean duration of the hospitalization was sixteen days (range, ten to twenty-six days).

Of the eighteen patients who had a total meniscectomy, two who lived in another country were lost to follow-up and two refused to be evaluated. The remaining fourteen patients (eleven girls and three boys) were available for follow-up and form the present study group (Table I). The mean age of these fourteen patients was also nine years (range, three to fourteen years) at the time of the operation. Radiographs were not made at the latest follow-up evaluation for one patient because she was pregnant. Each patient was examined by the same investigator (D. A. R.). The clinical findings were graded according to the rating system of the International Knee Documentation Committee¹⁰, which was originally developed to evaluate ligamentous lesions about the knee. The first section of the form is used to record demographic information, preoperative history, alignment of the knee, intraoperative findings, and current status of the menisci. The patient indicates his or her highest level of activity before the injury, preoperatively, and postoperatively. These data are recorded but not graded.

The circumference of the thigh was measured, fifteen centimeters proximal to the superior pole of the patella with the knee in full extension, to determine the degree of atrophy of the quadriceps.

Osteoarthrotic changes and the femorotibial angle were assessed on the anteroposterior weight-bearing radiographs of the eleven knees in the eleven patients who had unilateral involvement and were compared with those of the contralateral knee.

Radiographically evident osteoarthrosis was graded with use of the system developed by Tapper and Hoover²², which is based on the criteria of Fairbank⁶. These criteria include flattening of the lateral femoral condyle, the formation of a ridge along the lateral femoral condyle, narrowing of the joint space, and the formation of spurs and sclerosis of the tibial plateau. Grade 0 indicates a normal knee; grade 1, squaring of the tibial margin; grade 2, flattening of the femoral condyle and squaring and sclerosis of the tibial plateau; grade 3, narrowing of the joint space or hypertrophic changes, or both; and grade 4, all of the changes to a more advanced degree.

	Results

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Preoperatively, eleven knees had a lack of extension, eight had snapping, seven were painful, and two had swelling on the lateral side. One patient had the sensation of the knee giving way (Table I). The indications for the meniscectomy included a tear of the meniscus, increased mobility of the joint, or thickness of the meniscus that caused pain and snapping that interfered with activities of daily living.

The intraoperative findings included no lesion in three knees, a tear of the discoid meniscus in six, increased meniscal thickness in four, a cyst in three, and increased mobility of the joint in one.

According to the rating system of the International Knee Documentation Committee¹⁰, seven knees were normal (grade A), six were nearly normal (grade B), three were abnormal (grade C), and one was severely abnormal (grade D) at the time of the latest follow-up. Thirteen knees (ten patients) were given a grade of A in the subjective-assessment category. The grade in the subjective-assessment category was D for one patient (one knee) who had had operative removal of loose bodies twenty-two years after the initial meniscectomy. This patient also had osteochondritis dissecans of the lateral femoral condyle. The subjective grade was C for two patients (two knees) who had a decreased level of activity. Nine years after the initial meniscectomy, osteochondritis dissecans developed in one of these patients and progressed, resulting in a severe deformity of the lateral femoral condyle. The second patient had recurrent swelling of the affected knee and weakness of the quadriceps; however, diagnostic arthroscopy, which was performed ten years after the meniscectomy, did not reveal any abnormal findings. The subjective grade was D for one patient (one knee) who had severe pain after prolonged sports-related activities.

Twelve knees were asymptomatic (grade A). Four knees were moderately painful and had swelling and a history of giving-way (grade B). The knee that was grade D in the subjective-assessment category was severely painful during sports activities (grade C in the symptoms category). None of the knees had grade-D symptoms. One of four patients who had intermittent cramping of the treated extremity was found to have stenosis of the popliteal artery fourteen years after the meniscectomy.

Sixteen knees had full extension and fourteen had full flexion. One patient who had an extension deficit of 10 degrees (grade C) had no symptoms and rated the knee as normal. Two knees lacked 10 degrees of flexion (grade B), and one knee, which had a severely deformed lateral femoral condyle because of osteochondritis dissecans, lacked 20 degrees of flexion (grade C).

Eight knees had ligamentous instability: seven were grade B and one was grade C in this category. Anteroposterior translation was increased three to five millimeters (grade B) in four of these eight knees and six to ten millimeters (grade C) in one knee. The latter knee also had slightly increased mediolateral translation and recurrent swelling; however, the results of the pivot-shift and reversed pivot-shift tests were negative. The remaining three knees had three to five millimeters of varus-valgus rotation (grade B).

Four patients had a 2.0 to 3.5-centimeter decrease in the circumference of the thigh of the treated extremity compared with the circumference of the contralateral thigh. Three of the four patients had weakness and difficulty with weight-bearing activities. The patient who had a severe deformity of the lateral femoral condyle had severe atrophy of the quadriceps (a 3.5-centimeter decrease in the circumference of the thigh).

Four patients had had a reoperation before the last follow-up evaluation. One, who had recurrent swelling, had diagnostic arthroscopy that did not reveal any abnormal findings. Two patients who had osteochondritis dissecans had arthroscopic removal of loose bodies or arthroscopic débridement. One patient had femoral angiography because of cramping and pain in the limb when she walked; the angiography revealed stenosis of the popliteal artery, which was treated operatively.

Osteoarthrosis was noted in ten of the eleven knees that were compared with the untreated, contralateral knee. The osteoarthrosis was characterized by sclerosis of the lateral tibial plateau in nine knees, formation of a ridge on the lateral femoral condyle in five, flattening of the lateral half of the lateral condyle in seven, spurring of the lateral tibial plateau in seven, and one to two millimeters of narrowing of the lateral joint space in four (Figs. 1 and 2). The maximum degree of narrowing did not exceed two millimeters. One knee did not have any osteoarthrosis (grade 0), four had grade-1 osteoarthrosis, two had grade-3 osteoarthrosis, and four had grade-4 osteoarthrosis.

View larger version (145K): [in this window] [in a new window]   Fig. 1. Case 2. Anteroposterior radiograph, made twenty years after a meniscectomy, showing the formation of a ridge along the margin of the lateral femoral condyle as well as spurring and sclerosis of the tibial plateau (arrows) in the right knee. The latest overall grade was B, according to the system of the International Knee Documentation Committee10.

View larger version (140K): [in this window] [in a new window]   Fig. 2. Case 4. Anteroposterior radiograph, made almost twenty-two years after a meniscectomy, showing flattening and formation of a ridge along the margin of the lateral femoral condyle, narrowing of the joint space, and spurring of the tibial plateau (arrowheads) in the left knee. The latest overall grade was A, according to the system of the International Knee Documentation Committee10.

	Discussion

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A normal lateral meniscus is shaped like the letter c, forming five-sixths of a circle, and is larger and thicker than a normal medial meniscus. It covers the dome-shaped lateral and tibial plateau and forms a congruent surface for the lateral femoral condyle. The lateral meniscus can be displaced anteroposteriorly as much as twelve millimeters¹⁸. Together with the popliteal tendon, the lateral meniscus stabilizes the knee against excessive posterolateral rotational forces. A total meniscectomy increases the degree of anteroposterior translation and, to a lesser extent, the degree of varus rotation.

Smillie²¹ described three types of discoid menisci: "The primitive type ... shows a complete disc without any suggestion that it was ever intended to be a meniscus; the central zone and the short free central margin are thick. The intermediate type ... is less massive and less complete; it is thinner, to the point of transparency in the central zone. The infantile type ... approaches the normal, differing in the greatly increased breadth of the middle segment."

Watanabe et al.²⁴ also classified discoid menisci into three types: complete, incomplete, and the Wrisberg-ligament type⁵. With the Wrisberg-ligament type, the posterior meniscotibial attachment is absent, resulting in a hypermobile meniscus. This type often becomes symptomatic, whereas the complete and incomplete types are usually asymptomatic⁵.

The statement by Smillie²¹ that "the menisci exist as cartilaginous discs at an early stage of development, and ... the congenital discoid meniscus is due to occasional persistence of the foetal state" is no longer accepted as true. Smillie suggested that the shape of a normal meniscus is the result of gradual absorption of the central part of an originally complete plate during the latter half of fetal life. However, Kaplan¹⁴ studied fetal material and found that the menisci did not have a discoid shape at any stage of embryonic development. Furthermore, Kaplan dissected the knees of various primates and other mammals as well as several types of reptiles and birds and never found a discoid meniscus, although he did find some circular menisci. Kaplan concluded that the discoid shape develops gradually after birth in knees in which an absence of the attachment between the tibia and the lateral meniscus results in abnormal motion of the meniscus.

A discoid meniscus not only covers a larger area of the tibial plateau but also is much thicker than a normal meniscus^12,21. Ikeuchi¹² studied forty-nine excised discoid lateral menisci and noted a maximum thickness of fourteen millimeters (minimum, four millimeters). Smillie²¹ examined fifteen discoid and thirty normal (nondiscoid) menisci and found that the discoid menisci had a thicker-than-normal central portion (especially the free margin), but the greater thickness did not extend to the periphery.

A normal intact meniscus absorbs 50 to 70 percent of the load transmitted to the tibiofemoral joint¹¹ by increasing the area of load transmission by 40 to 50 percent¹⁸. Ihn et al.¹¹ performed a total lateral meniscectomy in five human above-the-knee amputation specimens. With the use of pressure-sensitive film, they demonstrated a decrease in the mean contact area and an increase in focal stress concentration. Even a small remnant of meniscus, along the rim of the condyle, was found to decrease the stress concentration.

A discoid lateral meniscus is more common than a discoid medial meniscus and causes symptoms mainly in children and adolescents^4,9,19, usually as a result of a tear of the posterior segment⁹. The most frequent symptoms associated with a discoid lateral meniscus, as reported in the literature^3,4,9,20 and found in our study, are a history of locking of the knee, pain, and a snapping sound. In the present study, the mean duration of symptoms before operative intervention was twelve months (range, one to twenty-four months).

Ikeuchi¹² reported that the prevalence of discoid menisci, as seen during various arthroscopic procedures on the knee, was 17 percent; however, he did not provide information on the total number of knees or the time span during which these procedures were performed. Discoid menisci have been reported more frequently in Asian countries than in other regions of the world^12,15. Kim et al.¹⁵ found a discoid meniscus in seventy-seven (14 percent) of 534 knees that were evaluated arthroscopically between July 1990 and September 1992. Fujikawa et al.⁸ pointed out that, in Japan, most problems related to the menisci in children are due to a discoid lateral meniscus. In the study by Mayer et al.¹⁷, 5 percent of 300 cadaveric knees had a discoid meniscus.

Athroscopic partial meniscectomy is the treatment of choice for a discoid meniscus^{3,4,7,9,12,20}. However, despite the advances in arthroscopic techniques and instruments, a symptomatic discoid lateral meniscus remains difficult to treat^3,20. Aichroth et al.³ noted the need for technical skill and experience in treating this condition. They recommended an arthroscopic partial meniscectomy for a complete or incomplete tear of a discoid meniscus with a stable posterior tibial attachment, and they recommended a total meniscectomy for an unstable Wrisberg-ligament-type meniscus, to avoid leaving an unstable rim. Ikeuchi¹² reported the results of arthroscopic partial or total meniscectomies that had been performed to treat discoid menisci in forty-nine knees between 1968 and 1980. A partial meniscectomy was performed in nine knees; peripheral reattachment, in three; and total meniscectomy, in thirty-seven. In twenty-nine knees, the posterior fragments were first detached arthroscopically and the excision was completed through a two-centimeter-long anterior arthrotomy that also permitted reefing of the lateral aspect of the capsule to prevent lateral instability. The authors noted that the arthroscopic meniscectomies were very difficult because of the increased size and thickness of the meniscus.

The results of the present study differ from those of the study by Washington et al.²³ in that, in the present study, only seven of seventeen knees had no subjective or objective symptoms or changes and could be considered clinically normal at the latest follow-up evaluation. Washington et al. reported a good or excellent result in thirteen of eighteen knees at a mean of seventeen years (range, eight to twenty-eight years). Radiographs made for nine knees (eight patients), at a mean age of fifteen years (range, seven to twenty-six years), showed evidence of slight narrowing of the joint space in three knees. The greater number of good or excellent results reported by Washington et al. may be related to their use of different rating system. We used the more rigorous system of the International Knee Documentation Committee¹⁰, in which the worst grade in any category is considered the final overall grade. With this system, a knee cannot be graded as normal if there is a lack of extension of as little as 10 degrees, even if the patient rates the knee as normal in the subjective assessment.

Manzione et al.¹⁶ evaluated the results of partial or total lateral or medial meniscectomy in twenty patients (twenty knees) at a mean of six years (range, three to fourteen years). The mean age of the patients was fifteen years (range, five to sixteen years) at the time of the operation. Grade-I osteoarthrosis was noted in sixteen knees, and grade-II or III osteoarthrosis was noted in four. There was no association between the degree of the osteoarthrosis and the site of the meniscectomy, the type of meniscal tear, or whether the meniscectomy had been partial or total.

Wroble et al.²⁵ reported the results of total meniscectomy in forty-one knees (thirty-nine patients) at a mean of twenty-one years (range, ten to thirty-five years). The age at the time of the operation ranged from six to fifteen years. (mean, fourteen years). Twenty-four medial and eighteen lateral menisci were removed (one knee had a bicompartmental meniscectomy). At the time of the latest follow-up, only eleven of the forty-one knees were asymptomatic. Osteoarthrotic changes were evident on the radiographs of thirty-seven knees. Twenty-six patients had an unsatisfactory result according to questionnaire that elicited responses regarding pain, swelling, stiffness, giving-way, and problems with activities of daily living. The patients (eleven knees) who were followed for more than twenty-six years had significantly more unsatisfactory results (more severe pain, swelling, and limitations in activities of daily living) (p < 0.05) than the patients who were followed for less time. On the basis of their findings, those authors recommended repair of peripheral tears; if this is not possible, they recommended a partial rather than a total meniscectomy.

Abdon et al.¹ reported the results of total meniscectomy in eighty-nine children (eighty-nine knees) at a mean of seventeen years (range, ten to twenty-eight years). Seventy-seven normal and twelve discoid menisci were removed, and forty-five lateral and forty-four medial meniscectomies were performed. According to the patients' assessments of symptoms and activity level, sixty-six (74 percent) of the patients were pleased with the outcome, even though only fifty-two (58 percent) had a satisfactory objective result according to the rating scale of Tapper and Hoover²². Significantly poorer results were recorded after the lateral meniscectomies (p < 0.05), although the reason for this finding was not clear.

Aichroth et al.³ reviewed the results of treatment of sixty-two discoid menisci in fifty-two children. The mean duration of follow-up was six years (range, two to eighteen years), and the mean age at the time of the operation was eleven years (range, four to eighteen years). Forty-eight knees had a total meniscectomy, six had a partial meniscectomy, and eight were treated nonoperatively. On the basis of the grading system described by Ikeuchi¹², the result was excellent for twenty-three knees (37 percent), good for twenty-nine (47 percent), and fair for ten (16 percent). There were early degenerative changes in three knees that had had a lateral total meniscectomy. Three patients, who were followed for eleven, thirteen, and eighteen years, had evidence of osteoarthrosis. Aichroth et al. agreed with Hayashi et al.⁹ that the axial alignment of the extensor mechanism and the pliability of the immature tissues in a child allow the knee to adapt to the stresses of activity, thereby preventing early osteoarthrosis.

Four of the patients in the present study had atrophy of the quadriceps, which is an indirect sign of problems related to the knee. Atrophy was described in adults by Tapper and Hoover²² and in children by Wroble et al.²⁵.

Subsequent procedures are also indicative of ongoing problems. Four of our patients had a second operation. Osteochondritis dissecans developed in the lateral femoral condyle of two of the treated knees, nine and twenty years after the meniscectomy. It is difficult to find a relationship between the total meniscectomy and the late onset of osteochondritis, but it may be due to the increased focal stress concentration after total meniscectomy. Unlike Aichroth et al.³, we did not find osteochondritis dissecans at the time of the operation in any of our patients. We also did not find instability to be as much of a problem as Wroble et al.²⁵ and Ikeuchi¹² did after meniscectomy of discoid lateral menisci in children.

The most important difference between our results and those in the literature^{3,4,7-9,12,20,23} was related to the radiographic changes. We found osteoarthrosis in ten of eleven knees, whereas Aichroth et al.³ found changes in only three of sixty-two knees, eleven, thirteen, and eighteen years after the meniscectomy. Washington et al.²³ found slight changes in three of nine knees. Manzione et al.¹⁶ described radiographic changes in sixteen of twenty patients, Abdon et al.¹ described such changes in fifty-seven of eighty-nine knees, and Wroble et al.²⁵ described such changes in thirty-seven of forty-one knees. One knee in the present study had grade-0 osteoarthrosis, four had grade-1 osteoarthrosis, two had grade-3 osteoarthrosis, and four had grade-4 osteoarthrosis. We did not find any association between the radiographic changes and the clinical outcome.

On the basis of our findings of persistent symptoms in ten of seventeen knees and evidence of osteoarthrosis in nine of eleven knees at the latest follow-up evaluation, we believe that total meniscectomy for the treatment of a discoid meniscus in children should be avoided whenever possible.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Regional Hospital, 8853 Lachen, Switzerland.

Department of Orthopedic Surgery, Kantonsspital Bruderholz, 4101 Basel, Switzerland.

Department of Pediatric Orthopedics, Children's Hospital, University of Basel, 4058 Basel, Switzerland.

	References

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