MATSUSUE, YOSHITAKA

UEO, TOYOJI

YAMAMURO, TAKAO

Kyoto University Research Information Repository

TitleArthroscopic Resection of the Shelf (Mediopatellar Plica) inthe Knee under Local Anesthesia in Outpatient ClinicAuthor(s)MATSUSUE, YOSHITAKA; UEO, TOYOJI; YAMAMURO,TAKAOCitation日本外科宝函 (1991), 60(3): 176-183Issue Date1991-05-01URL http://hdl.handle.net/2433/203791RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversityArch Jpn Chir 60(3), 176～183, Mai., 1991 臨床Arthroscopic Resection of the Shelf (Mediopatellar Plica) in the Knee under Local Anesthesia in Outpatient Clinic YosHITAKA MATSVSVE, ToYOJI UEo, TAKAO YAMAMVRO Department of Orthopaedic Surgery, Faculty of Medicine, Kyoto University, Kyoto, Japan Received for Publication, Feb. 1, 1991 Summary Forty-two knees with symptomatic mediopatellar plicae (shelves) were managed using the oper-tive method under local anesthesia. Of these, thirty-one knees had isolated mediopatellar plicae, and eleven had other associated intra-articular pathologic condition, such as meniscal tear, lateral patellar tracking, osteochondritis dissecans, and minor osteoarthritic changes. The clinical results were excellent or good in thirty-se河 n(88%) patients, fair in five patients after an average follow-up of twenty-five months. No case showed deterioration after surgery. Because there are no definitive criteria for the indication of shelf resection, arthroscopic resection of the shelf under local anesthesia is recommended if there is any possiblity of it being the cause of knee pain目Introduction Several kinds of fold, pleats, or shelves of synovial membrane may exist in the knee joint3,4,l3). Of these, the medial plica is considered to be the one most likely to cause symptoms1ム仏8,9,10,14)The accurate diagnosis of medial plica syndrome, however, is not able to be obtained either from symptoms, physical findings, or conventional tests including arthrography. Nowadays, it is obvious that with the help of endoscopy the diagnostic accuracy has improved considerably. During the last five years, we have exclusively carried out arthroscopies under local anesthesia in the out-patient clinic. Obtaining an ac仁uratediagnosis in the early phase of the treat-ment process can reduce both the time and cost of the entire treatment process. The purpose of this study was to review the results of endoscopic surgery of the symptomatic mediopatellar plica under local anesthesia and to emhasize the fact that a shelf observed by chance during routine arthroscopic examination in the out-patient clinic should be resected arthroscopically even if the pathogenetic evaluation is not completely definitive. Ke 、worckArthroscopicresection -shelf knee -Local anesthesia -Outpatient clmic 索引語鏡視下切除，棚，膝，局所麻酔，外木Present address:54 Kawahara cho, Shogo凧 Sakyoku、Kyoto,606, Japan ARTHROSCOPIC SHELF RESECTION UNDER LOCAL ANESTHESIA 177 Materials and Methods Arthroscopic resection of mediopatellar plica was performed in 51 knees ( 48 patients) during the period from 1984 to 1988. During this five-year period, al the 238 arthroscopic procedures were per-formed in the out-patient clinic under local anesthesia by one of the authors (Dr目 UEO)at Kyoto University Hospital in Kyoto, Japan. Forty-two knees of 39 patients were reviewed, with follow-up periods ranging from 12 to 59 months (average, 25 months) after surgery. The age of the patients ranged from 11 to 53 years, with a mean of 25 years. Twenty-one were male and 18 were female. Of the patients operated on for the purpose ofresecting their synovial shelf, thirty-one patients (73%) were under 30 years of age and eight patients (19%) were over 40 years of age・Therepatients had bilateral involvement. The duration of symptoms prior to arthroscopy averaged 25 months ( 1 to210 months). About one third of the patients had a history of continuous sports activity, and another one third of the patients have had a traumatic accident involving the knee. Thirty-eight percent of the pa-tients had no unusual history of the knee. Follow-up data were obtained through interviews and physical examinations in 31 knees, and through telephone interviews in 11 knees. Symptomatic results were graded by the patients themselves as excellent, good, fair, or poor. A result of excellent was noted in patients with no symptoms and who showed ful activity; a good result was noted in patients with improved symptoms after surgery, but who showed some inter-mittent symptoms during ful activity; and a fair result was noted in patients with no change of symp-toms. A poor result was used if symptoms worsened after arthroscopy. Operative method All arthroscopic examinations and surgical procedures were performed under local anesthesia in the outpatient clinic. One nurse, who prepares the operative field with drape, was sufficient to do the test, because the patient could move his leg freely. 20 cc of 1% Xylocaine with epinephrine and 20 cc of 2% Xylocaine without epinephrine were mixed to prepare the local anesthetic. After the skin and underlying soft tissue had been infiltrated with 7 cc ofXylocaine, 15 cc ofXylocaine was in-jected into the joint cavity. After 10 minutes of Xylocaine injection, the joint was filled with saline, and a Stroz 4 mm arthroscope was inserted into the joint through the anterolateral portal. When the need for resection of the shelf was indicated during arthroscopy, infiltration of the skin and underly-ing tissue of the antero-lateral suprapatellar region with Xylocaine was performed. The arthroscope was then removed from the knee and reinserted through a suprapatellar lateral portal, allowing the Fig. 1. These photographs show irregularity (left side) and flaki時（rightside) of the medial femoral condyle m conjunction with shelf (mediopatellar plica) 178 日外宝 第60巻第3号（平成3年5月）Table 1. Asociated intra articular pathologies (Group I) Meniscus tear 3 After meniscal repair Subluxation of the patella 2 ACL insufficiency 2 Osteoarthritis (mild) 2 Osteochondritis dissecans plica to be viewed from above. A pair of basket forceps or scissors was inserted through the anterolateral portal, and subtotal resection of the shelf was performed under direct arthroscopic vi・sion. The time for the arthroscopic shelf resection was not more than 15 minutes longer than a sirn-ple arthroscopic examination. Our indication to resect the sh巴Ifwas based on such pathological findings of the medial femoral condyle as fibrillation irregularity, or flaking, that were detected in co町unctionwith the shelf (Fig. 1 ). The series was divided into two groups based on the presence or absence of associated intra-ar-ticular pathologic conditions. Group I, consisting of 31 knees (28 patients), in仁ludedknees in which the only pathologic finding was a hypertrophic mediopatellar plica. Group I, consisting of 11 knees (11 patients), included knees in which intra-articular pathologic conditions beyond the plica and localized chondromalacia were noted. Associated intra-articular pathologic conditions included meniscal tears, ACL, insu伍ciency,lateral patellar tracking, osteochondritis dissecans, and osteoar-thritis. All these conditions were slight and needed for no additional surgical procedures (Table 1) Table 2. Symptoms in 42 knees with shelves Pain when ascending or descending the stairs Pain when walking Pain during sports activities Pain when standing up or sitting down Pain during long periods of standing Pain when resting Pain when stretching the knee Clicking during flexion or extension Difficulties encountered when trying to sit Giving-way Joint effusion in the correct Japanese manner 71% 24% 27% 24% 12% 22% 2% 41 % 27% 22% 5% ARTHROSCOPIC SHELF RESECTION UNDER LOCAL ANESTHESIA 179 Table 3. Physical findings in 42 knees with shelves. Tenderness above the medial patella・femoraljoint line Tenderness on the medial or lateral femoro-tibial joint line Positive McMurray test Palpable fibrous band on the edge of the medial femoral condyle Snapping Atrophy of quadriceps muscle Results Symptomatology and physical findings 56% 51 % 33% 23% 21 % 15% There was no significant difference in symptoms and physical findings between Group I and Group I, thus the symptoms and physical findings are discussed together. Pain was the chief complaint in 87 % of the patients, which was most often felt when ascending or descending the stairs (71%). Clicking was part of the symptom complex in 41% of the patients, but was noted in only 10% of the patients as chief complaint. Giving-way felt in 22%, and joint swelli月 wascomplained by only 5% of the patients (Table 2). The most common physical findings in the present series were those related to the medial com-partment of the knee. Tenderness at the lateral part of the femoro-tibialjoint space was detected in only 5% of the patients. Palpable fibrous band on the edge of the medial femoral condlye was note in 23%, snapping in 21%, and atrophy of quadriceps muscle in 15% of the patients (Table 3). Table 4. Arthroscopic findings of the cartilage of the patella and medial femoral condyle. Pathological findings Pathological findings of the patella of the medial femoral condyle no particular change 62% fibrillation 41 % fibrillation 24% irregularity 19% flaking 8% flaking 17% softening 6% softening 5% no particular change 19% 180 日外宝第60巻第3号（平成3年5月）Table 5. Symptomatic results by Group excellent good fair poor Total 23 14 5 。(55%) (33%) (12%) Group I 21 8 2 。(68%) (26%) ( 6%) Group I 2 6 3 。(18%) (55%) (27%) Table 6. Symptomatic results by age Table 7. Symptomatic results by type of the shelves us-ing Sakakibara’s clasification. excellent good fair poor Type excellent good fair Under 40y.o. 22 9 3 。(34 joints) 8(16 joints) 7 6 3 Over 40y.o, 5 2 。 C (21 joints) 13 6 2 ( 8 joints) D ( 5 joints) 3 2 。Radiographic findings In radiopgraphy, Group I showed no particular findings. In Group I, one of the radiographs showd mild osteoarthritic findings in the medial compartment, one showed the healing stage of osteochondritis dissecans of the medial femoral condyle, and two showed mild patellofemoral sublux-ation. There was no marked joint space narrowing, osteophyte formation, or subchondral sclerosis in the involved compartment. Arthroscopic findings There was no significant difference in the pathological findings of the patella and medial femoral condyle between Group I and Group I. Overall results of arthroscopic findings are shown in Table 4. As to pathological findings of the patella, more than half of the cases (62%) showed no particular change, and fibrillation was noted in 24% of the cases. As to pathological findings of the medial femoral condyle, fibrillation was the most common findi時（41%)and irregular町 wasdetected in 19% of the cases. There was no particular change in 19% of the cases, thus much l巴sextensive than in the patella (Table 4）ーSymptomatic results In total, excellent and good results were achieved in 88% of the patients and no poor result was obtained. In Group I, excellent and good results were obtained in 94% of the patients. In Group I, excellent results were achieved in only 18%, but this method was effective in 73% of the patients in spite of the associated minor pathologic changes. No worse result was obtained (Table 5). The results obtained for patients under 40 years or age were 65% for excellent and 26% for good. The results for those over 40 years of age were 12% for excellent and 63% for good; three qua口erof the patients showed excellent and good results (Table 6). Shelves were divided into three groups (B, C, and D) accordi時 totheir shape using SAKAKIBARA’s classification (13). More favorable results were obtained in patients who had highly developed shelf structure. Excellent or good results were obtained in 80% of B type shelves, 90% of ARTHROSCOPIC SHELF RESECTION UNDER LOCAL ANESTHESIA 181 C type, and 100% of D type (Table 7). Discussion Today, most knee surgeons would agree that a mediopatellar plica can cause knee pain. Although the incidence of medial plica involvement has been reported to be from 20% to 45%1・9・13>, the indication of resection of symptomatic mediopatellar plica is not clearly defin巴dand the results of plica surgery are at present controversial1・14l. In general, it is considered that a plica becomes pathologic if for any reason the fold is converted into a bowstring5). Trauma or strenuous sports ac” tivity is related to the cause of plica syndrome in more than half of the cases. In our study, one third of the patients had trauma involving the knee and another one third were involved in athletic sports activities. However, the remaining one third were not involved in either trauma or spo口sact-ivities. No correlation was found in the clinical results between these three groups. Arthroscopically, pathological findings of the medial femoral condyle were found to be more common than those in the patella in this study, although PATEL10) reported that medial facet chon-dromalacia was noted more frequently than anteromedial femoral chondral irregularity in conjunc-tion with medial patellar plica. Only two patients showed no pathologic change both in the patella and the medial femoral condyle in this study. Concerning the operative method, we performed release or segmental resection of the shelf in the early cases. However, we experienced five cases of recurrence of the symptomatic shelf, as con-firmed by arthroscopy later. Therefore, subtotal resection of the shelf was routinely performed in most cases, and it is important that the medial capsule should not be injured so as not to cause pain by scar formation, and the distal attachment of the shelf to the fat pad is resected as much possible. There have been many studies on arthroscopy under local anesthesia in recent years6・7・11) The advantages of performing the arthroscopy under local anesthesia are as follow; 1) The burden to the patients is less than those under lumbar or general anesthesia. 2) The patient can be observe the findings that are projected on the display and receive an adequate explanation of the findings from the doctor. 3) The pathology under dynamic conditions, as shown in Fig. 2, can be obtained when considering the patell-femoral relationship, inculuding the extent of synovial shelf impingement. Therefore, the authors recommend that arthroscopy for patello-femoral disorders should be perform-ed under local anesthesia. Fig. 2. These photographs show the relationship between the synovial shelf and medial femoral condyle under dynamic conditions under local anesthes肌＼Vhenthe quadriceps muscle is relaxed, the shelf does not con匂ctthe medial femoral condyle (left side). On the other hand, the shelf impinges on the condyle (arrow) when the quadriceps is actively contracted (right side) 182 日外宝第60巻第3号 （平成3年5月）Some authors have emphasized that the diagnosis of plica syndrome must be done be exclusion of other associated intra articular pathologica findings5l. It is no doubt that the excision of the typical symptomatic plica, which is larger, thick and tight and impinges on the medial femoral con-dyle, gives excellent results in most cases4・8・9・10l However、R1cHMON012lreported that in patients with associated conditions, good to excellent results were obtained in 69% of those knees. In our series, good to巴xcellentresults were obtained in 88 % of al knees and the resection of shelves was effective in 73% of the patients in spite of the combined minor intra-articualr pathologic changes, although complete relief of pain was obtained in only two knees ( 18%) In symptomatic results, 75% of the patients over 40 years of age showed favorable outcome after the operation, thus it is em-phasized that even in older patients the resection of the shelf was effecti、rto some extent and there was no patients who complained of increased pain after surgery. SAKAKIBARA14l showed the existence of a shelf which shows no pathological condition but an ir-ntablejoint capsule due to some patellofemoral morbidity. He suggested that in this state stretching of the normal shelf might cause pain, and concluded that the indication of shelf surgery in this type should be limited because improvement of pain is inferior to that in the typical shelf syndrome. However, the authors advocate that the shelf be ex〔isedif there is any possibility of it being the cause of knee pain, because in the present study group a relatively favorable outcome was obtained after this operation and no adverse effects were obser、ed. In addition, the excision of the shelf under local anesthesia requires minimal additional time, around 15 minutes, which is not a hea＼＇’y burden to the patient. References 1) Broom MJ, Fulkerson JP: The plica syndrome: a new perspective. Orthop C!in North Am 17: 279-281, 1986. 2) Hardaker WT、Whipple,TL, Baset FH: Diagnosis and treatment of the plica syndrome of the knee. J Bone Joint Surg 62-A: 221-225, 1980 3) Iino S: Normal arthroscopic findings of the knee joint in adult cadavers. J Jpn Orthop Assoc 14：・ 467-525,1939 4) Jackson R W, Marshall DJ, F叩sawa Y: The pathologic med凶 shelf. Orthop Clin North Am 13 307-312, 1982. 5) Kinnard P, Levesque RY: The plica syndrom~ ： a syndrome of controversy. Clin Orthop 183: 141 143, 1984 61 Klein ¥', Schulitz KP: Outpatient arthroscopy under local anesthesia守 ArchOrthop Traumat Surg 96 131-134, 1980. 7) McGinty, JB, Matza RA: Arthroscopy of the knee: evaluation of out-patient procedure under local anesthesia. J Bone Joint Surg 60-A: 787-789, 1978 8) Moller H: Incarcerating mediopatellar synovial plica syndrome. Acta Orthop Scand 52: 357-361, 1981 9) Munzinger U守 Ruckstuhリ， ScherrerH. G引 hwendN: Internal derangement of the knee joint due to pathologic synovial folds: The mediopatellar plica syndrome. C!in Orthop 155: 59-64, 1981 10) Patel D: Arthoroscopy of the phcae: sy:-iovial folds and their significance. Am J Sports Med 6: 217-225, 1978. 1) Pevy JK: Outpatient arthoroscopy of the knee under local anesthesia. Am J Sports Med 6: 122-127, 1978. 12) Richmond JC, McGinty JB: Segmental arthoroscopic resection of the hypertrophic mediopatellar plica. Clin Orthop 178: 185-189, 1983. 13) Sakakibara J: Arthroscopic study on Ii的、 band{plica synovialis mediopatelaris ). J Jpn Orthop Aso< 50 513-522, 1974. 14) SakakibaraJ: Pathogenesis of the shelf syndrome. First International Congress of Knee and Orthopaedic Sports Medicine Section of W.P.0.A. in Yokohama, Japan, 1989, Abstract: p. 96 ARTHROSCOPIC SHELF RESECTION UNDER LOCAL ANESTHESIA 183 和文抄録外来における局麻下タナ切除術松末吉隆，上尾豊二，山室隆夫有痛性の42関節の内側膝蓋骨膜鍛（タナ）を局所麻 (88%）に，臨床上優または良の成績が得られ，可は酔下の関節鏡視下に切除した その内31関節が単独の 5例で悪化例は認められなかった．タナ切除の正確なタナで， 1関節は，半月板損傷，膝蓋骨亜脱臼，離断 適応が明らかでない以上，膝関節痛の原因として可能性骨軟骨炎や軽度の関節症変化などの関節内病変を合 性が示唆されるならば，外来局所麻酔下での鏡視下タ併していた．術後平均25ヶ月の経過観察期間で， 37例 ナ切除を行ってよいと考えられる

外来における局麻下タナ切除術

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外来における局麻下タナ切除術

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