Case 12 Flashcards
(10 cards)
Patient is a 19-year-old college volleyball player who sustained an injury 3 months prior to her surgical evaluation when she had a direct injury to the knee with persistent mechanical type symptoms anterior medially. For over 3 months she treated with physical therapy, athletic trainer, anti-inflammatories bracing and intra-articular cortisone injection with incomplete relief.
She had persistent left-sided medial knee pain with mechanical symptoms concerning for snapping popping, with an inability return back to her sports.
Pmh is notable for collegiate athlete, non-smoker, medically healthy. On BCP
Physical examination was concerning for meniscal pathology.
She had full range of motion both active and passive normal strength assessment.
leg with stable to ligamentous stressing with a negative Lachman exam she did have medial and lateral joint line tenderness,
McMurray’s exam was positive, pain is recreated with deep knee flexion with a positive Apley compression test.
X-ray interpretation was normal. Laboratory work was deferred.
Radiology report documented a small posterior medial meniscus tear, however I did not serial images demonstrating a full tear and I interpreted as more as meniscal signal thus I interpreted as equivocal. I also did not identify any other findings on the MRI that would characterize her symptoms.
In determining her indications for surgery my thought process was as follows. Her presentation was most consistent with a traumatic medial meniscal tear with persistent mechanical symptoms despite conservative care. Her physical exam and advanced imaging was in concordance.
She had significant symptoms for 3 months or more and had exhausted conservative treatment options.
Moreover, she was in off season athlete so she would have time to recover if we proceeded with surgical intervention. Clinically she did have significant symptoms, a previous extension block, so I was also aware that this may be an occult bucket-handle tear.
Finally patient was an athlete and she was not able to return to level of performance she desired where is a knee arthroscopy give her a chance.
Differential diagnosis also include cartilage pathology or an anterior medial symptomatic plica. I indicated her for diagnostic knee arthroscopy primarily with anticipation for meniscal repair versus debridement and potential cartilage evaluation and potential for synovectomy especially with the plica excision. Even though I was unsure based on the MRI report she did have medial joint line tenderness and McMurray’s that is much more accurate for meniscal tear in the setting of a young traumatic meniscal type tear with symptoms.
Once the patient was taken to the operating room prepared for meniscal debridement versus all inside repair or small possibility for the need to open and perform an inside-out meniscal repair. I placed her supine on the bed with ability to flex the knee if warranted. I began with a comprehensive diagnostic arthroscopy
The medial compartment identified normal healthy cartilage. I probed the meniscus and found it to be stable to stress without displacement and without identifiable superior or inferior tear. I did identify what I felt to be a small posterior medial meniscal tear that may have been her pain generator. I felt it does not meet criteria for repair as it was a white- white zone of less than 10% of the meniscus so underwent a meniscal debridement using a combination of rotary shaver and straight biter to debride any unstable rim.
I I also which was most notable for an anterior medial plica with erythema on the medial femoral condyle that could be identified as a symptomatic plica. I chose to excise the plica. This was via a rotary shaver
I then completed the diagnostic arthroscopy without any additional pathology identified. Duration of surgery was 25 minutes with 15cc estimated blood loss.
Patient general postop course was uncomplicated. She did have a delay in returning to sport secondary to Covid restrictions. I saw her at 2 weeks, 6 weeks, 3 months and 6 months which is consistent with my routine recovery program. My last follow-up visit at 9 months status post surgery and she is generally doing well. Recovery was considered generally routine however she did have some slower than expected recovery and this is most likely due to inability to access physical therapy during Covid. When I did see her at the 9-month visit she did meet return to sport criteria based in office screening.
