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Functional Outcome of Partial Meniscectomy On Discoid Meniscus.

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1 FUNCTIONAL OUTCOME OF PARTIAL MENISCECTOMY ON DISCOID

MENISCUS

1

I Gusti Agung Gde Dendy 2I G N Wien Aryana

1

Resident of Orthopaedic and Traumatology Department, Sanglah General Hospital, Udayana University, Bali 2

Staff of Orthopaedic and Traumatology Department, Sanglah General Hospital, Udayana University, Bali

BACKGROUND

Discoid meniscus is common congenital anatomical anomaly of the meniscus. A discoid meniscus has abnormal morphology. It is thicker and covers more of the tibial plateau. The cause of discoid meniscus is unknown, though there are some theories by Smillie and Kaplan. Watanabe describe discoid meniscus as complete, incomplete, and Wrisberg type. The physical examination usually showed pain, swelling, joint tenderness, effusion, limited extension, and classic audible “snapping knee”. The most accurate criteria for the diagnosis of discoid meniscus on radiograph is MRI. Surgical treatment necessary for those symptomatic conditions by partial or total meniscectomy.

CASE PRESENTATION

A 9-year-old female presented with a one-year history of knee pain in her right knee. Physical examination revealed a limited range of motion of flexion and extension also audible click sound McMurray. On radiograph showed a flattening of tibial plateau and widening of joint space with an increasing ratio of the minimal meniscal width to maximal tibial width on the coronal slice of more than 20%. Patient undergone partial meniscectomy and 6 months post operatively, patient showed a good result based on WOMAC index.

DISCUSSION

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2 sound. WOMAC Score after partial meniscectomy the score was 8,3 %. The score indicate there is no significant pain, joint stiffness and difficulty on physical activity. After the operation patient can do her normal daily activity, and there is no complained on her knee anymore.

CONCLUSIONS

This study has shown that treatment of discoid meniscus with Partial Meniscectomy in children is consider to get satisfactory functional outcome based on WOMAC index

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3 BACKGROUND

Discoid meniscus, a common anatomical anomaly of the meniscus, was first described by Young in 1889. In the fetus the meniscusis is disc-like; if this shape persists, symptoms are likely.1 Discoid meniscus is an uncommon meniscal anomaly that occurs more frequently laterally than medially.2 The normal menisci differentiate within the limb bud from mesenchymal tissue early during fetal development. They gain mature anatomical shape at the 14th week, without ever possessing a discoid shape. By 9 months of life, the central third becomes avascular, and only the peripheral third retains its blood supply at adulthood. The inner two-thirds receive nourishment via diffusion from the intra-articular fluid. In adults, the C-shaped medial meniscus covers 50% of the medial tibial plateau and is connected firmly to the joint capsule.3

A discoid meniscus has abnormal morphology. It is thicker and covers more of the tibial plateau. The incidence of lateral discoid meniscus is 0.4% to 17%5, compared to 0.06% to 0.3%for the medial one. 20% of discoid lateral meniscus are bilateral, whereas bilateral discoid medial meniscus is rare. The incidence is estimated to be 3% to 5% in the general population and slightly higher in Asian populations The precise cause of discoid meniscus is unknown, though there are some theories.3,4

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4 sense in cases with normal posterior attachments. The congenital theory is supported by reports of familial transmission and of the anomaly occurring in twins.3,4

Smillie first classified discoid meniscus into three types: the primitive type that affects the whole disc, the intermediate type that is smaller and less complete, and the infantile type, which differs in that the middle segment has greatly increased breadth. Watanabe et al classified various types of lateral discoid meniscus based on its arthroscopic appearance and on the basis of the degree of coverage of the lateral tibial plateau and the presence or absence of the normal posterior meniscotibial attachment as; complete, incomplete, and Wrisberg type.2 Discoid menisci with normal peripheral attachments were labeled as either type I (complete) or type II (incomplete) according to the degree of coverage of the lateral tibial plateau. Type III (also the Wrisberg ligament type) includes cases without normal posterior meniscotibial attachment, thus allowing increased mobility and producing the classic „„snapping knee‟‟ syndrome. Wrisberg-type discoid menisci often occur at a younger age than complete or incomplete types and are unassociated with trauma. If an incomplete or complete discoid meniscus is torn, symptoms are similar to those of any other meniscal tear: lateral joint line tenderness, clicking, and effusion.3,4

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5 attachment.3,4 On physical examination, the patient may present with pain, swelling, joint line tenderness, effusion, limited extension, and anterolateral bulge at full flexion. McMurray test may be positive, but it is not typical especially in young children. A true locking is a rare presentation; whereas pseudo-locking more often occur, but requires no specific maneuver to restore range of motion.3,4

Conventional imaging radiograph usually revealed widened lateral joint space, cupping of the lateral tibial plateau, Lateral joint space narrowing, squaring of the lateral femoral condyle, cupping of the lateral tibial plateau, tibial eminence hypoplasia, and fibular head elevation.3,4 MRI is widely used to diagnose the discoid meniscus. The most accurate criteria for the diagnosis of discoid meniscus on MRI are a ratio of the minimal meniscal width to maximal tibial width (on the coronal slice) of more than 20% and a ratio of the sum of the width of both lateral horns to the meniscal diameter (on the sagittal slice showing the maximal meniscal diameter) of more than 75%. Both ratios had a sensitivity and specificity of 95% and 97%.3,4,5

Treatment of discoid meniscus depends on its type, concomitant symptom, duration of the symptom and the patients‟ age. Tears of complete or incomplete discoid menisci that cause pain and snapping within the knee and that show a hypermobile medial segment but intact peripheral attachments are best treated by subtotal meniscectomy or a so-called saucerization of the mobile fragment by arthroscopic techniques.2 The width of the remaining peripheral rim is an important feature to consider when meniscectomy is performed.3 The width of the remaining peripheral rim should be between 5 mm and 8 mm to prevent instability of the remnant, as such instability may cause a secondary meniscal tear.4 Wrisberg-type discoid meniscus, treatment generally is total meniscectomy, either open or arthroscopic. Subtotal meniscectomy alone leaves an unstable rim of meniscus that cause further problems. Although total meniscectomy of a nondiscoid lateral meniscus may lead to progressive osteoarthrosis in children and adults, children with discoid menisci seem less prone to these degenerative changes.2 Many more recent studies have shown that total removal leads to a high subsequent risk of degenerative osteoarthritis compared with partial meniscectomy with preservation of a stable peripheral rim.4

CASE PRESENTATION

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6 walking on the stairs or bending the knee. Knee examination showed no deformity but a limited range of motion of flexion and extension. The patient had lateral joint line tenderness.

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7 Patient underwent an operation through arthroscopy with partial meniscectomy on her right knee. Several days post operatively, patient trained to gain the motion of her knee by ROM exercise. The patient returned to her activity, recovering full flexion and extension of the knee and no limitations in activity daily living. Six months follow up post operative, patient had no symptoms and showed a good result.

DISCUSSION

Discoid meniscus is an uncommon congenital condition of the knee.1,3,4 Discoid meniscus more common in Asian population with higher incidence in lateral meniscus.3 The etiology of discoid meniscus still unknown whereas there was many theory to describe this phenomenon. Our case of discoid meniscus is complained by 9 years old girl who experience pain on her knee for one year. The pain initially with history of trauma previously. On physical examination we revealed joint tenderness and limitation of bending on the knee while walking or squatting. For the purpose of confirming of her complaint we performed conventional X-Ray examination. However, our case has abnormal radiographic findings that related to the discoid meniscus. We found flattening of tibial plateau and widening of joint space on lateral tibial plateau.

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8 right knee. MRI of knee is consider the best predictor of radiological methods to confirmed discoid meniscus especially on asymptomatic patient.3,4 After diagnose of discoid of meniscus was confirmed, we educated her parent then suggested an operation to diminished the complaint. Surgical treatment of discoid menisci should be considered only if the patient is symptomatic.4,5 We performed the partial meniscectomy on her right knee with arthroscopy procedure. We rebuild an anatomical shape of the meniscus.

We used WOMAC index to evaluate the functional outcome after the operation. We take a questioner based on WOMAC Score at follow up. WOMAC index consist of three item points: pain, joint stiffness, difficulty in physical activity.6 After the partial meniscectomy patient followed up and examined with WOMAC Score. Patient can do normal daily activity without pain and limitation of movement on her right knee. She can do flexion and extension on her knee fully without pain and audible click sound. WOMAC Score after partial meniscectomy the score was 8,3%. The score indicate there is no significant pain, joint stiffness and difficulty on physical activity. After the operation patient can do her normal daily activity, and there is no complained on her knee anymore. Partial meniscectomy showed on excellent outcome for our case without presence another harmful condition.

CONCLUSION

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9 REFERRENCE

1. Solomon L, Karachalios T. The Knee. Apley‟s System of Orthopaedics and Fracture Ninth Edition. London 2010; 20: 561

2. Canaly, Beaty. Campbell‟s Operative Orthopaedics, 11th ed. Philadelphia : Mosby Elsevier, 2007

3. Yaniv M, Blumberg N. The Discoid Meniscus. J Child Orthop 2007; 1: 89-96

4. Ye Sun, Qing Jiang. Review of Discoid Meniscus. Orthopaedic Surgery. 2011; 3(4):219–223

5. Lee JH , Wang SI, Park JH, Lim YJ . A Case of Asymmetric Bilateral Discoid Medial Menisci. J Korean Knee Soc 2011; 23(4): 55-60

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