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Rapid Meniscal Degeneration After Arthroscopic Saucerization for Discoid Lateral Meniscus in a 17-Year–Old Baseball Player

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Rapid Meniscal Degeneration After Arthroscopic Saucerization for Discoid Lateral Meniscus in a 17-Year–Old Baseball Player Central Annals of Sports Medicine and Research Case Report *Corresponding author Kazuhisa Hatayama, Department of Orthopaedic Surgery, Japan Community Health Care Organization Rapid Meniscal Degeneration Gunma Central Hospital, 1-7-13 Koun, Maebashi, Gunma, 371-0025, Japan, Tel: +81-27-221-8165; Fax: +81- 27-224-1415; Email: after Arthroscopic Saucerization Submitted: 31 March 2017 Accepted: 24 April 2017 Published: 25 April 2017 for Discoid Lateral Meniscus ISSN: 2379-0571 Copyright without Tear: A Case Report © 2017 Hatayama et al. OPEN ACCESS Kazuhisa Hatayama* and Masanori Terauchi Department of Orthopaedic Surgery, Japan Community Health Care Organization Keywords Gunma Central Hospital, Japan • Discoid lateral meniscus • Meniscectomy • Saucerization Abstract • Degeneration We present a case of rapid meniscal degeneration after arthroscopic saucerization for discoid lateral meniscus in a 17-year–old baseball player. He was diagnosed posterior cruciate ligament injury and discoid lateral meniscus (DLM) without degeneration or tear by magnetic resonance imaging (MRI). We performed arthroscopic saucerization with the aim to preserve as much meniscal function as possible before it injures. Two and a half months after saucerization, he sprained his right knee and presented with knee pain. MRI and arthroscopy revealed a radial tear of the middle segment of the remaining lateral meniscus, meniscal degeneration and horizontal cleavage around the tear site. These findings were not seen at the initial operation. Subtotal meniscectomy was performed and 3 mm of the peripheral rim was preserved. MRI of three months after re-operation showed subchondral bone marrow edema in the lateral tibial condyle. Six months after re-operation, he was unable to resume satisfactory sports activity because of persistent knee pain during training. We do not recommend saucerization for asymptomatic DLM without tear. It may not have an effect preventing subsequent meniscal injury. ABBREVIATIONS with arthroscopic saucerization, which is resection of the central portion of the discoid meniscus, leaving behind a peripheral rim DLM: Discoid Lateral Meniscus; LM: Lateral Meniscus; PCL: of 6 to 8 mm of the meniscus, in conjunction with stabilization Posterior Cruciate Ligament; MRI: Magnetic Resonance Imaging of the remnant rim by suture repair when peripheral tear is INTRODUCTION present [6,8-10]. However, DLM can be susceptible to severe degeneration or complex tears with degenerative horizontal Discoid lateral meniscus (DLM) is a relatively rare tear or radial tear [2,3,11], and total or subtotal meniscectomy morphologic abnormality of the lateral meniscus (LM). The true is inevitable in some menisci. Hence, DLM without tear should probably be reshaped in the form of a normal meniscus before DLM injury to preserve as much function as possible. We report incidence of DLM remains undefined because symptoms are into three types according to the arthroscopic appearance: type a case of a patient who developed a radial tear with degeneration often absent. Watanabe et al. [1], classified discoid meniscus I for complete discoid meniscus, type II for incomplete discoid in the middle segment of LM only two months after arthroscopic meniscus, and type III for unstable discoid meniscus caused saucerization. by absence of the posterior meniscotibial ligament (Wrisberg- ligament type). It is thought that abnormal shape and thickness, CASE PRESENTATION In June 2015, a 17-year-old boy presented with right knee pain the discoid meniscus are associated with the increased incidence after his knee hit on the ground while he was playing baseball. A ofdisorganized meniscus tears collagen [2,3]. fibers and abnormal meniscal motion of The importance of meniscal functions such as shock absorber posterior cruciate ligament (PCL) injury and DLM by magnetic and load distributors of the knee joint is well accepted [4,5]. Some resonancefew days later, imaging an orthopedist (MRI). The at aorthopedist unaffiliated informedpractice diagnosed him that authors have reported more frequent arthritic changes after DLM often leads to meniscal injury, and recommended him subtotal meniscectomy for DLM than after partial meniscectomy arthroscopic saucerization before injury. Thus, he was referred [6,7]. Therefore, recent literature promotes meniscal preservation to our hospital for having an operation in July. Cite this article: Hatayama K, Terauchia M (2017) Rapid Meniscal Degeneration after Arthroscopic Saucerization for Discoid Lateral Meniscus without Tear: A case Report. Ann Sports Med Res 4(2): 1105. Hatayama et al. (2017) Email: Central On physical examination during his first visit, he had no Therehemarthrosis was no tendernessand limited of range the lateral of motion joint in space. his right The knee,McMurray 0˚ to test105˚. could Posterior not be drawer performed test becausewas 2+ positiveof his knee with pain. firm MRI end showed point. the midsubstance tear of the PCL and incomplete discoid lateral meniscus without tear (Figure 1a, b). He hoped to reshape the a) b) c) DLM and we decided to proceed with knee arthroscopy in August. Figure 2 Although arthroscopy revealed a midsubstance tear of the PCL, operation. (a) Arthroscopy revealed the partial midsubstance tear of Arthroscopic viewings from anterolateral portal at the first the anterolateral bundle remained partially intact (Figure 2a), the PCL (arrow), the anterolateral bundle remained partially intact (arrowhead) and (b) incomplete lateral discoid meniscus without and incomplete lateral discoid meniscus without degeneration or degeneration or tear. (c) Saucerization was performed. Remaining tear (Figure 2b). The LM was resected the central portion leaving meniscal instability was not revealed. 8 mm of the peripheral rim (Figure 2c). The remaining meniscus could not be pulled to the center of the tibial plateau by probing, so we assessed it stable. One day after surgery, isometric muscle exercise, range-of-motion exercise, and weight bearing were started. One week after surgery, closed kinetic chain exercise was started, and we allowed playing baseball at two months after surgery. Two and a half months after surgery, he sprained his right knee pain. He consulted the local clinic and was diagnosed with a radialknee while tear of running LM by MRI.to catch He wasa fly referred ball and to presented our clinic withone weekright a) b) after re-injury. On physical examination, he had knee effusion and Figure 3 (a) Coronal and (b) sagittal T2*-weighted gradient-echo tenderness in the lateral joint space. The McMurray test could not images on MRI at re-injury shows radial tear of the middle segment of the remaining LM with degeneration and horizontal cleavage tear. belimited performed range ofbecause motion of in his his knee right pain. knee, MRI -10˚ showed to 50˚. radialThere tearwas of the middle segment of LM with degeneration and a horizontal cleavage tear (Figure 3a,b). We performed arthroscopy two weeks after re-injury. Arthroscopy revealed radial tear of the middle segment of LM, and meniscal degeneration and horizontal cleavage around the tear site, which was not seen at initial operation (Figure 4a). Subtotal meniscectomy was performed and 3 mm of the peripheral rim was preserved (Figure 4b). The postoperative rehabilitation was after re-operation, right knee pain developed after running a) b) 15performed km and thehe consultedsame as after our hospital.the first operation.He had no Threeknee effusionmonths and full range of motion in his right knee. He presented lateral Figure 4 Arthroscopic viewings from anterolateral portal at the compartment pain and there was tenderness at the lateral joint second operation. (a) Arthroscopy revealed a radial tear of the middle segment of the LM as well as meniscal degeneration and horizontal cleavage around the tear site. (b) Subtotal meniscectomy was performed preserving 3 mm of the peripheral rim. space, lateral femoral condyle and lateral tibia plateau. The Mc Murray test was negative. The MRI showed a low signal intensity area in the lateral tibial condyle on T1-weighted imaging and a high signal intensity area on proton density image with fat suppression (Figure 5). The re-tear of LM was not seen. We judged the excessive load to articular cartilage and subchondral bone of lateral tibial condyle after lateral meniscectomy, and instructed the patient to reduce sports activities when his knee pain was aggravated. Six months after re-operation, he was unable to Figure 1 (a) Coronal, (b) Sagittal turbo spin-echo fat-saturated proton resume satisfactory sports activity because of persistent knee density images on preoperative MRI show incomplete discoid lateral pain during training. Informed consent of the patient and his meniscus without tear. parents was obtained for the publication of this case report. Ann Sports Med Res 4(2): 1105 (2017) 2/4 Hatayama et al. (2017) Email: Central contribute to rapid degeneration after surgery [3]. Furthermore, PCLand theinjury decrease may be in related the number to the of meniscal the collagen degeneration fibers in DLM because may it causes changes in biomechanical properties of LM during knee MRI following meniscectomy has been reported to be correlated withflexion the [13]. extent The of incidence meniscectomy, of bone and marrow it is suggestedsignal changes that theon excessive load to articular cartilage and subchondral bone is caused by abnormal stress distribution after meniscectomy [14]. Several studies have demonstrated a greater
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