Subacromial plica as a cause of impingement in the shoulder

The subacromial bursa is the largest bursa in the body. In 1934, Codman described the presence of subacromial plicae, similar to the suprapatellar plicae found in the knee. It is recognized that plicae in the knee can cause anterior knee pain with impingement against the patella in young persons. We investigated the possibility that a similar situation exists with plicae of the subacromial bursa. The aims of this study were to document the prevalence of bursal plicae seen at bursoscopy during arthroscopic subacromial decompression of the shoulder and to assess whether there is any pattern in the occurrence of these plicae, as well as the relationship to impingement lesions seen at bursoscopy. Between January 1996 and July 2001, all cases undergoing arthroscopic decompression were evaluated for anatomic-pathologic changes of the subacromial bursa, including the presence of plicae and impingement lesions. A total of 1732 cases complying with inclusion criteria were recorded, with plicae observed in 104 (6.0%). The occurrence of plicae showed a highly significant younger age predilection (P = .0008, chi(2) test) but no differences between sexes or sides. The occurrence of subacromial plicae was highly associated with the combined severity of the impingement lesion on the acromial and bursal side. Plicae were most common in shoulders showing an impingement lesion on the cuff bursal side, with no impingement lesion on the acromial side. The odds of the impingement lesion being milder on the acromial side was 3.41 times higher in shoulders with a plica compared with shoulders without a plica. This suggests that impingement of the cuff may be due to the plica itself. This study is the first to describe the presence of subacromial plicae in living subjects and correlates with previous anatomic studies. The younger age predominance correlates with the findings of plicae in the knee. Our findings suggest that subacromial plicae may be a cause of impingement in young patients.     

An arthroscopic technique of demonstrating the pathomechanics of the suprapatellar plica.

The suprapatellar plica or incomplete suprapatellar septum of the knee is a recognized cause of knee pain in some patients and appears to exist in others without causing any symptoms. To date no clear method of demonstrating the pathomechanics of the suprapatellar plica by arthroscopic means has been described. This article describes a new technique of visualizing this structure arthroscopically and demonstrating the mechanism of its morbidity. By the use of a proximal viewpoint via the lateral suprapatellar portal, we have shown that the suprapatellar plica impinges on the medial femoral condyle and is trapped between the quadriceps mechanism and the femoral trochlea when the knee is flexed beyond 70 degrees. We conclude that our arthroscopic method may show the mechanism of production of symptoms of the pathological suprapatellar plica.     

Snapping elbow caused by hypertrophic synovial plica in the radiohumeral joint: a report of three cases and review of literature

The snapping elbow caused by hypertrophic synovial radiohumeral plica is a rare form of lateral elbow impingement. In this article we report on hypertrophic radiohumeral synovial folds in three male patients, aged 54, 65 and 27 years. All three patients suffered isolated lateral elbow pain, painful snapping and unsuccessful conservative treatment over at least 5 months (range 5–9 months, mean 7.7 months) prior to surgical treatment. None of the patients had lateral epicondylitis, instability, osteochondrosis dissecans, loose bodies, arthritis or neurological disorders. Upon clinical examination the range of motion in the respective painful elbows was found to be normal in all three cases, but a painful snapping occurred between 80° and 100° of flexion with the forearm in pronation. While there were no pathologic findings in standard radiographs, magnetic resonance imaging (MRI) revealed hypertrophic synovial plicae in the radiohumeral joints associated with effusion in each of the diseased elbows. Arthroscopic examinations confirmed the presence of a hypertrophic synovial plica in all three radiocapitellar joints, and revealed a transient interposition and compression of the folds in the articulation from extension until 90°–100° elbow flexion, with replacement beyond 90° elbow flexion with a visible jump. Surgical management in all three cases comprised arthroscopic diagnosis confirmation and removal of the synovial plicae, leading to excellent outcomes at 6–12 months follow-up.     

Classification of the suprapatellar septum considering ontogenetic development.

At the end of the 4th fetal month, the suprapatellar septum completely separates the knee joint cavity from the suprapatellar bursa. A perforation of the septum normally occurs at the end of the 5th fetal month. Mechanical factors, such as the pressure and friction of the quadriceps tendon on the condylar surface, are said to determine the form and extent of the perforation. Anatomic studies of adult knee joints revealed four variants in the further development of the suprapatellar septum, namely, a completely preserved septum (complete septum), a perforated septum with the communication between suprapatellar bursa and knee joint cavity differing in localization and number (perforated septum), a residual septum in the form of a fold that is almost always in a medial localization (residual septum), or a completely involuted septum (extinct septum). The clinical term "suprapatellar synovial plica" should not be used as a synonym for the expression "suprapatellar septum." The suprapatellar synovial fold corresponds to the residual septum and thus is only one of the four types of the suprapatellar septum.     

Arthroscopic anatomy of the infrapatellar plica

The infrapatellar plicae, ligamentum mucosum, were examined by arthroscopy in 200 knees. They were classified into five patterns according to the characteristics of the morphologic findings: separate type in 121 cases (60.5%), split type in 27 cases (13.5%), vertical septum type in 21 cases (10.5%), and fenestra type in 2 cases (1.0%). The remaining 29 cases (14.5%) did not have any infrapatellar plica, which were defined as absent type. Hence, the incidence of the infrapatellar plica was 85.5% of the 200 knees examined. There was no significant difference between right and left knees in the distribution pattern of the plica types. The incidence of the intrapatellar plicae decreased as the age increased. Both knees showed the same pattern in the 9 of 16 cases in which a bilateral comparison of the infrapatellar plicae was made.     

Snapping plicae associated with radiocapitellar chondromalacia

Purpose: Painful snapping of the elbow joint is usually attributed to intra-articular loose bodies, instability, or medial dislocation of the triceps muscle over the medial epicondyle. We report our experience with 14 patients who were treated arthroscopically for snapping elbow that was found to be caused by hypertrophic synovial folds associated with radiocapitellar chondromalacia. Type of Study: Case series. Methods: The records of 14 patients who were treated arthroscopically for painful snapping elbows caused by intra-articular plicae were reviewed. There were 6 women and 8 men with an average age of 36 years (range, 27 to 48 years). Nine patients had had some type of trauma to the joint. Four patients had been previously diagnosed with lateral epicondylitis and 5 with intra-articular loose bodies. The average time from initial onset of symptoms to treatment was 13 months (range, 8 to 36 months). Average follow-up was 24 months (range, 6 to 66 months). Results: All patients complained of painful snapping in the posterolateral or anterolateral aspect of the elbow. The snapping occurred between 90° and 110° of flexion with the forearm in pronation. In 7 patients, the snapping was reproducible by passively flexing the pronated elbow, which we refer to as the flexion-pronation test. At the time of arthroscopic surgery, all patients had a thickened synovial plica that would snap back and forward over the radial head, usually associated with a chondromalacic area on the radial head. Twelve patients had complete relief of their snapping after surgery. One patient in whom there was associated posterolateral rotatory elbow instability did not improve. One patient became asymptomatic for 4 years but then had recurrence of her symptoms, which persisted despite 2 subsequent arthroscopies. Conclusions: The presence of synovial plicae in the radiocapitellar joint must be considered in the differential diagnosis of painful snapping elbow. Arthroscopy confirms the diagnosis and allows excision of the plica.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 491–495     

Arthroscopic treatment of symptomatic type D medial plica

We aimed to review the results of subtotal arthroscopic resection of symptomatic type D medial plica. We retrospectively evaluated 23 knees with symptomatic type D medial plica in 22 patients without other intra-articular pathology. All patients complained of chronic knee pain that had not been alleviated by medical treatment or physical therapy. In only three (13%) of the patients studied was the plica diagnosed pre-operatively with magnetic resonance imaging. The type D medial plicae in our series were classified as fenestrated (14 knees), torn (5 knees), or reduplicated (4 knees). Fibrotic changes in the plicae and degenerative changes on the medial femoral condyle were found in 16 knees Patellofemoral chondromalacia was present in three knees Arthroscopic partial resection was performed in all patients. Comparative Lysholm Knee Scale scores before and after surgery revealed a significant clinical improvement (pre-operative status, 67.19 ± 8.05 vs. post-operative status, 90.57 ± 9.80; P < 0.001). Type D medial plica should be considered as a possible cause of chronic knee pain. Arthroscopic partial resection of the plicae in symptomatic patients gives satisfactory results. Research was performed at the Medical Faculties of Baskent University and Istanbul University.     

The development of synovial plicae in human knee joints: An embryologic study

An embryologic study about the development of the human knee joint cavity was carried out with special attention to the formation of synovial plicae, using a total of 116 knees of embryos and fetuses. The incidence of synovial plicae in the fetal stage was also investigated. Formation of joint space starts at the middle of the interzone at around 8 weeks of gestation. Multiple small cavitations around the femoral condyle and patella coalesce to form larger cavitations. At around 10 1/2 weeks, the knee joint consists of a single cavity with synovial lining. At certain sites, such as at the medial part of patello-femoral and the infrapatellar regions, mesenchymal tissue strands remain. They may become plica. In the fetal stage from 11 to 20 weeks, an infrapatellar plica was found in 50% of specimens, a suprapatellar plica in 33%, and a mediopatellar plica in 37%. Only the infrapatellar plica showed a decrease in incidence.     

Clinical diagnosis of medial plica syndrome of the knee: a prospective study

Clinical diagnosis of symptomatic medial plica that causes anteromedial knee pain is poorly defined in the literature; therefore, arthroscopy is considered to be the gold standard for diagnosing this condition. We report our system of clinical diagnosis for medial plica syndrome that is based on patient history and our criteria for clinical examination. This prospective study included 48 symptomatic patients (66 knees) with clinical suspicion of pathological medial plica based on five essential and four desirable criteria. All patients underwent arthroscopic examination to confirm or disprove the clinical diagnosis and also treatment. Arthroscopy confirmed the clinical diagnosis of medial plicae in 44 patients (62 knees) for a diagnostic accuracy of 91.7% (95% confidence interval [CI]: 80% to 97.7%) and sensitivity of 100% (95% CI: 92% to 100%). The 44 patients with pathological medial plicae at arthroscopy were treated by arthroscopic resection. Thirty-nine patients (55 knees) showed satisfactory outcome after arthroscopy (95% CI: 75.4%, 96.2%). Our method of clinical diagnosis of pathological medial plica is simple, inexpensive, noninvasive, and reliable. We conclude arthroscopy is successful in treating this condition.     

误诊为半月板损伤的弹响膝122例分析

目的探讨误诊为半月板损伤患者弹响膝的发生机制、临床表现、诊断和关节镜治疗。方法回顾性分析122例术前误诊为半月板损伤的弹响膝患者资料,所有患者均接受膝关节镜手术。分析不同病因导致膝关节弹响的部位、响度、发生频率、镜下表现,最终评价关节镜手术疗效。结果许多疾病均可出现膝关节弹响,最常见原因为半月板损伤,其次是关节内游离体、软骨病变、滑膜病变、髌股关节紊乱、韧带及肌腱损伤等。其弹响各有特点,关节镜诊治后91．8％弹响症状完全消失,少数患者残余部分症状？结论膝关节弹响来源多样,半月板源性的弹响最为常见。掌握弹响特点有助于术前正确诊断,提高手术疗效,避免过度医疗。关节镜手术是诊治弹响膝的金标准。     

膝关节髌下皱襞的临床意义

目的:观察膝关节镜下髌下皱襞结构的变化,探讨膝关节髌下皱襞的临床意义。方法:回顾性总结分析膝关节镜手术病例400例,男177例,女223例;年龄9~79岁,平均42岁。术前均有膝关节疼痛、肿胀和交锁等现象,保守治疗无效,行膝关节镜检查及镜下手术。术中证实单纯的髌下皱襞病变11例,术前有膝前区疼痛症状者8例,疼痛区域模糊不定者3例,膝关节反复肿胀、积液者2例;术前诊断为半月板损伤4例,关节软骨损伤2例,髌股关节骨性关节炎1例,髌下脂肪垫损伤4例。11例均行膝关节镜下髌下皱襞切除术。结果:400例膝关节镜手术中发现有髌下皱襞结构的284例(71%);有髌下皱襞病变的52例(13%),其中单纯的髌下皱襞病变11例(2.75%)。髌下皱襞病变镜下表现为髌下皱襞肿胀、增厚、纤维化、丧失弹性,与髁间凹产生撞击。11例单纯髌下皱襞病变均行关节镜下髌下皱襞切除术,术后随访9例,2例失访,随访时间3~24个月,平均14个月。疗效评定优7例,良1例,可1例,差0例,优良率88.89%。结论:髌下皱襞具有明确的临床意义,其病变可以引起临床症状。     

膝关节髌下皱襞的临床意义

目的:观察膝关节镜下髌下皱襞结构的变化,探讨膝关节髌下皱襞的临床意义。方法:回顾性总结分析膝关节镜手术病例400例,男177例,女223例;年龄9⁷9岁,平均42岁。术前均有膝关节疼痛、肿胀和交锁等现象,保守治疗无效,行膝关节镜检查及镜下手术。术中证实单纯的髌下皱襞病变11例,术前有膝前区疼痛症状者8例,疼痛区域模糊不定者3例,膝关节反复肿胀、积液者2例;术前诊断为半月板损伤4例,关节软骨损伤2例,髌股关节骨性关节炎1例,髌下脂肪垫损伤4例。11例均行膝关节镜下髌下皱襞切除术。结果:400例膝关节镜手术中发现有髌下皱襞结构的284例（71%）;有髌下皱襞病变的52例（13%）,其中单纯的髌下皱襞病变11例（2.75%）。髌下皱襞病变镜下表现为髌下皱襞肿胀、增厚、纤维化、丧失弹性,与髁间凹产生撞击。11例单纯髌下皱襞病变均行关节镜下髌下皱襞切除术,术后随访9例,2例失访,随访时间3²4个月,平均14个月。疗效评定优7例,良1例,可1例,差0例,优良率88.89%。结论:髌下皱襞具有明确的临床意义,其病变可以引起临床症状。     

Anatomy of the medial suprapatellar plica and medial synovial shelf

The anatomy of the medial suprapatellar plica and medial synovial shelf was studied arthroscopically in 500 knees. The medical suprapatellar plica extended up to one third of the way across the suprapatellar pouch in 64.2% of knees, between one and two thirds in 4%, and two thirds or more in 31.6%. The medial synovial shelf was absent or vestigial in 36% of knees and broader than 1 cm in 13.2%. When both knees were examined arthroscopically, the similarity between the appearances of the plica and the shelf in the two knees was statistically significant. No relationship between age and the pattern of plica or shelf could be found. There was no association between large plicae and large shelves, but the shelf was absent significantly more often in knees with a narrow plica.     

Plica: Pathologic or Not?

A fold that occurs within a joint is referred to as a plica synovialis. Three such plicae are seen with regularity within the human knee joint. These folds are normal structures that represent remnants of mesenchymal tissue and/or septa formed during embryonic development of the knee joint, and can be seen during arthroscopic inspection of the knee joint. Controversy exists within the orthopaedic community as to whether a plica can develop pathologic changes sufficient to cause disabling knee symptoms. The author defines the clinical syndrome, describes the arthroscopic appearance of pathologic plica, and outlines nonsurgical and surgical methods of management of this uncommon condition.     

The superolateral approach: a better view of the medial patellar plica

When attempting to perform medial patellar plica surgery, the arthroscopist often finds that the three standard portals, namely, central, inferolateral, and midpatella lateral, offer poor visualization, awkward instrumentation, or both. This article suggests and describes the superolateral approach as a better arthroscopic portal for medial patellar plica surgery; while affording a sweeping, unobstructed view of the entire plica, this approach enables the arthroscopist to utilize the midpatella lateral portal for effective and convenient excision, with no damage to articular surfaces. The superolateral approach also offers excellent visualization of the suprapatellar pouch, the suprapatellar plica, and the patellofemoral joint. We further recommend the use of an infusion pump to improve knee distension, as well as the use of arthroscopic electrocoagulation to minimize postoperative hemarthrosis.     

膝关节内侧滑膜皱襞综合征的关节镜诊治

目的探讨膝关节内侧滑膜皱襞综合征的临床诊断、关节镜诊断及疗效。方法回顾分析1996年1月～2007年12月收治的420例诊断为膝关节痛或半月板损伤或滑膜皱襞综合征的患者,其中有70例内侧滑膜皱襞综合征患者。按Sakakibara法分析其关节镜下形态,在镜视下行皱襞切除术、挛缩内侧支持带松解术,随访分析其疗效。结果70例内侧滑膜皱襞综合征中,镜下A型8例,B型13例,C型24例,D型25例。经镜下行皱襞切除,获得随访43例,随访时间为6个月～5年,平均32个月,按Lysholm法进行疗效评定,优良率90.7%。结论关节镜仍是该病确诊的"金标准",镜下彻底切除滑膜皱襞、松解挛缩内侧支持带是治疗该病有效的方法。     

Usefulness of knee arthroscopy for diagnosis of knee pain in pediatric patients: comparison with preoperative clinical diagnosis

Purpose

To investigate the knee arthroscopic findings of pediatric patients with knee pain.

Subjects

Ninety-five knees of 94 patients (46 males and 48 females) aged 15 years or younger who underwent knee arthroscopy during a 4-year period from January 2007 were studied. The mean age at surgery was 13.5 (7–15) years. The mean interval from symptom onset to arthroscopic examination was 6.8 months (5 days to 2 years 10 months).

Results

The most common cause of knee pain was sports-related activities (64 knees). Other causes included falling from a moving bicycle (5 knees), while knee pain appeared with no defined reason in 14 knees. The most frequent final diagnosis based on knee arthroscopic findings was anterior cruciate ligament (ACL) injury (35 knees), followed by discoid lateral meniscus (16 knees), lateral meniscal tear (11 knees), and medial plica syndrome (9 knees), while no arthroscopic abnormality was observed in 8 of 95 knees. Among the 95 knees, the diagnosis based on preoperative physical tests and imaging findings was different from the arthroscopic diagnosis in 16 knees, 8 of which were diagnosed preoperatively as medial meniscal tear.

Conclusion

ACL injury and discoid lateral meniscus were the predominant conditions in pediatric patients who underwent knee arthroscopic surgery for knee pain. Knee arthroscopy is useful to provide a definitive diagnosis for knee pain in pediatric patients. Preoperative evaluations had a diagnostic accuracy of only 83.2 % and failed to diagnose conditions such as medial plica syndrome and chondral injury. Therefore, diagnosis before knee arthroscopy has to be interpreted with caution.     

Isolated suprapatellar bursitis: Computed tomographic and arthroscopic findings

A rare case of compartmentalized suprapatellar bursitis in the left knee of an 80-year-old man is presented. Computed tomographic (CT) scans following intravenous administration of contrast media showed a cystic mass between the quadriceps tendon and the anterior surface of the femur. Multiplanar reconstruction CT scans showed a mass superior to the patella, the wall of which was enhanced. Arthroscopic examination of the knee revealed a complete suprapatellar septum that separated the suprapatellar bursa from the knee joint cavity. Surgical excision of the bursa was curative. To our knowledge, multiplanar reconstruction CT and arthroscopic features of the isolated suprapatellar bursitis have not been illustrated previously.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp E10–E10     

Symptomatic infrapatellar plica

The purpose of this retrospective clinical study was to assess the clinical outcomes of a group of patients who underwent arthroscopic infrapatellar plica (IPP) excision, to determine whether the IPP was symptomatic or not, and the symptoms or signs in the patients clinical presentation and correlations between arthroscopic findings and the patients clinical presentation. We studied all patients undergoing arthroscopic resection of symptomatic IPP without other intraarticular abnormality at our department from February 1996 to April 2001. Fourteen patients with isolated IPP and with regular follow-up intervals were included. Arthroscopy findings, preoperative magnetic resonance imaging (MRI) findings, and clinical presentation were correlated. The mean duration of follow-up was 36 months with a range of 24–60 months. The IPP was found to be in a fenestra pattern in seven patients, separate (cordlike) pattern in five patients, and vertical septum pattern in two patients. IPP in all patients was excised with a powered instrument. Excellent and good results were obtained in 12 (89%) patients. Two patients had poor results. All patients had been documented as having pain; popping, or snapping with flexion and extension; giving way; and swelling. There was no correlation between IPP type and MRI findings with being symptomatic (p>0.05). It was found that IPP type was not a prognostic factor (p>0.05). IPP should be considered as a possible cause of knee pain when MRI imaging exhibits no other internal derangement.     

Arthroscopic findings in the knees of preadolescent children

Purpose: The aim of this review was to correlate the preoperative clinical diagnoses and the diagnostic arthroscopic findings in preadolescents with knee problems. We also studied the incidence of different types of knee pathology in this age group. Type of Study: Consecutive case series. Materials and Methods: Twenty-three preadolescents, 13 girls and 10 boys under the age of 13 years, presenting with mechanical knee problems underwent knee arthroscopy after clinical assessment. Results: Symptomatic plica synovialis was found to be the most frequent pathology (n = 8). This pathology was far more common in girls compared with boys. Anterior cruciate ligament injuries (n = 4) followed symptomatic plica synovialis in frequency. This was an isolated injury in all cases. The arthroscopic findings were negative in 4 patients. Conclusion: In 61% of preadolescent patients, the clinical diagnoses and arthroscopic findings were compatible and correct. The main error tended to be misdiagnosis of meniscal pathology (4 patients) and overdiagnosis (5 cases of negative arthroscopy).