Shaw-Ruey Lyu, M.D., Ph.D., and Chia-Chen Hsu, M.D.

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1 Medial Plicae and Degeneration of the Medial Femoral Condyle Shaw-Ruey Lyu, M.D., Ph.D., and Chia-Chen Hsu, M.D. Purpose: The purpose of this study was to evaluate and analyze the chronological changes of the pathologic medial plica and the chondral lesions on the medial femoral condyle. The relationship between the severity of the pathologic medial plica and that of the chondral lesions on the medial femoral condyle was also investigated. Type of Study: Retrospective case series study of consecutive patients who underwent arthroscopic surgery. Methods: A retrospective case series study was conducted to review the findings of 1,587 knees of 1,263 patients who had received arthroscopic surgery between 1989 and The medial plica was classified by its size and the severity of its gross pathologic change. The location and severity of the cartilaginous degeneration on the surface of the medial femoral condyle of these patients were also investigated. The correlation of patient age with the gross pathologic change of their medial plica and the severity of the cartilaginous degeneration on the surface of the medial femoral condyle was analyzed. Results: We found that 472 knees (29.7%) of 378 patients (29.9%) had the structure of the medial plica. The incidence was significantly higher (66.9%) in patients with osteoarthritic knees. The severity of the gross pathologic change of the medial plica was positively correlated with patients age. The size of the plica was found to be smaller in older patients. Two distinct areas of degenerative cartilaginous lesion related to the medial plica were found on the surface of the medial femoral condyle in 97% of the knees with the structure of the medial plica. The severity of the degeneration was positively correlated with patients age and the severity of the pathologic change of the medial plica. Conclusions: According to our observation, medial plica was more commonly found in patients with osteoarthritic knees. Cartilaginous degeneration on the surface of the medial femoral condyle could be found in most of the knees with a medial plica. The severity of the degeneration was positively correlated with the severity of the medial plica and patients age. Level of Evidence: Level III. Key Words: Knee Cartilage Degeneration Medial plica Osteoarthritis Abrasion phenomenon. The mediopatellar plica is a fold in the synovium representing an embryologic remnant in the development of the synovial cavity of the knee. It is found along the medial wall of the joint originating superiorly, extending obliquely and inferiorly, and inserting on the synovial lining of the infrapatellar fat pad. 1-4 It is generally agreed that this structure can produce knee symptoms and can be successfully treated by arthroscopic resection when it becomes From the Joint Center, Tzu-Chi Dalin General Hospital, Chiayi, Taiwan. Address correspondence and reprint requests to Shaw-Ruey Lyu, M.D., Ph.D., the Joint Center, Tzu-Chi Dalin General Hospital, No. 2, Min-Shen Road, Dalin, Chiayi, Taiwan by the Arthroscopy Association of North America /06/ $32.00/0 doi: /j.arthro inflamed, thickened, and less elastic During arthroscopic examination, different degrees of cartilaginous degeneration on the surface of the medial femoral condyle facing the medial plica have been observed by many investigators. 1,2,7,8,11,12,15,16 Most discussions have been focused on the mechanism of generation of the lesions and many authors have reported that the pathologic medial plica snaps or impinges against the underlying femoral condyle during knee motion and leads to erosive changes of the articular cartilage. 1,2,7,8,9,11,12,17 However, there have been no reports in the literature specifically discussing the chondral lesion; the incidence of this lesion in different types of medial plicae has not been investigated. Nor has the relationship between the severity of the chondral lesions on the medial femoral condyle and the severity of pathologic medial plicae been scrutinized. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 1 (January), 2006: pp

2 18 S-R. LYU AND C-C. HSU TABLE 1. Age Distribution and Incidence of Medial Plica Found in Each Subgroup of Patients According to Their Diagnosis Diagnosis No. of Knees (M/F) No. of Plicae (M/F) Age Range (Mean) Incidence % (M/F) Chondromalacia patella 428 (71/357) 121 (17/104) (47) 28.3 (23.9/29.1) Osteoarthritis 350 (91/259) 234 (49/185) (59) 66.9* (53.8/71.4) Meniscus tear 286 (181/105) 31 (20/11) (42) 10.8 (11.0/10.5) Ligament injury 254 (167/87) 43 (28/15) (39) 16.9 (16.8/17.2) Gouty arthritis 111 (102/9) 19 (17/2) (51) 17.1 (16.7/22.2) Rheumatoid arthritis 63 (8/55) 9 (1/8) (47) 14.3 (12.5/14.5) Others 95 (42/53) 15 (6/9) (42) 15.8 (14.3/17.0) Total 1,587 (662/925) 472 (138/334) (48) 29.7 (20.8/36.1) *P.0001 by 1-group variance t test. In this study, we retrospectively evaluated the operative findings of patients who underwent arthroscopic surgery for different pathologies. The incidence of medial plica in different diagnostic groups was evaluated. The appearance of the medial plica was examined and classified according to the severity of its gross pathologic change. The incidence, location, and severity of the cartilaginous degeneration on the surface of the medial femoral condyle facing the medial plica were also evaluated, and their relationship with patient s age was analyzed. The goal of our study was to investigate the chronological changes of the chondral lesions on the medial femoral condyle and the pathologic medial plica. The relationship between the severity of the chondral lesions on the medial femoral condyle and that of the pathologic medial plica was also examined. We hypothesized that the severity of these cartilaginous lesions is positively correlated with patient s age and the severity of the plical lesion. METHODS From August 1989 to May 2001, 1,587 arthroscopic surgeries were performed in 1,263 patients by the senior author (S-R.L.). The age and gender distribution and the incidence of the medial plica found in each subgroup of patients according to their main diagnosis are shown in Table 1. In this study, 472 knees (29.7%) of 378 patients (29.9%) who were found to have the structure of medial plica were included. There were 88 male patients (138 knees) and 290 female patients (334 knees). The mean age was 48 years (range, 13 to 79). These patients arthroscopic findings, recorded onto either videotape or CD-ROM, were reviewed together by the authors. Special attention was paid to the size and appearance of the medial plicae and their dynamic relationship with the cartilaginous degeneration on the surface of the facing medial femoral condyle. The location and severity of the cartilaginous degeneration over the medial femoral condyle facing the medial plicae were also inspected and recorded. In the early stage of our study, the unique appearance of the medial plica and the adjacent chondral lesion convinced us of the need to develop more comprehensive classification systems for this investigation. We classified the medial plicae into 3 types to represent their size according to their relationship with the facing medial femoral condyle during arthroscopic examination in full extension position (Fig 1). A type A plica has no direct contact with the medial femoral condyle. A type B plica rides onto but not beyond half of the medial femoral condyle. A type C plica is the largest, covering more than half of the medial femoral condyle. We also classified them into 5 grades of severity according to their gross appearance (Fig 2). A grade I plica looks like a membrane; its margin is somewhat transparent. It is soft in consistency when palpated by a probe. The grade II plica loses its transparency; it is hypertrophied and thickened, but it is still soft in consistency. A grade III plica looks like a fibrotic band; it is thicker than grade II plica and is elastic in consistency. In a grade IV plica, the sign of wearing appears in addition to fibrosis; its margin becomes frail and fibrillated. The grade V plica is an inflamed grade IV lesion and various degrees of focal synovitis can be found adjacent to the medial plica. In most cases, synovectomy should be performed on a grade V lesion so its structure can be visualized clearly. Two distinct foci of cartilaginous lesions were found on the edge and anterior part of the medial femoral condyle (Foci A and B in Fig 3). The appearance of these focal cartilaginous lesions is unique and is different from what has been described in the classical arthroscopic classification of cartilaginous lesions.

3 MEDIAL PLICAE AND CHONDRAL LESIONS 19 FIGURE 1. The medial plica is classified into 3 types according to its relationship with the medial femoral condyle when the knee joint is distended during arthroscopic examination. (A) Type A, no direct contact with the medial femoral condyle. (B) Type B, riding onto less than half of the medial femoral condyle. (C) Type C, covering more than half of the medial femoral condyle. We also classified these lesions by a novel system into 5 stages according to the gross appearance of their severity (Fig 4). In the stage I cartilaginous lesion, neovascularization and pannus formation are found over the margin of the lesion. Softening of the cartilage can be confirmed by palpation with a probe. The stage II lesion has all the findings of the stage I lesion plus flattening and indentation of the cartilage. The stage III lesion includes partial-thickness cartilaginous damage; the cartilage becomes fissured and fibrillated. In a stage IV lesion, some areas of subchondral bone are exposed; a shallow gutter representing the imprint of abrasion caused by the medial plica can be identified. In a stage V lesion, the subchondral bone is completely exposed to form a deep gutter. To investigate the relationship of the severity of the chondral lesion on the medial femoral condyle with that of the plical lesion, an arbitrary scoring system was defined to represent the severity of the cartilaginous degeneration on the medial femoral condyle (Table 2). All values were presented with mean and standard deviation. One-group variance t test was used to detect

4 20 S-R. LYU AND C-C. HSU FIGURE 2. Grading of the severity of the medial plica according to its gross appearance. (A) Grade I, membranous, soft in consistency. (B) Grade II, hypertrophied and thickened. (C) Grade III, fibrosis, hard in consistency. (D) Grade IV, fibrosis and marginal fibrillation. (E) Grade V, fibrosis, marginal fibrillation, and synovitis.

5 MEDIAL PLICAE AND CHONDRAL LESIONS 21 FIGURE 3. Location of the cartilaginous lesions on the medial femoral condyle facing the medial plica. the significance of the incidence of medial plica in each preoperative diagnosis among others. And comparison of each pair using a Student t test was used to detect the differences in distribution of patient age and total degenerative score of the medial femoral condyle among each type or grade of medial plical lesion. Pairwise comparisons were performed between different types or grades of plical lesion when statistical significance was found. P.05 for all statistical tests in advance. All statistical analysis was carried out using JMP (Version ; SAS Institute Inc., Cary, NC) Statistical Discovery Software. RESULTS The incidence rate of the medial plica was 29.7% in this series. It was higher in female (36.1%) than in male (20.8%) patients. In patients with the diagnosis of osteoarthritis, the incidence of medial plica was significantly higher (66.9%) than that of others (Table 1). The age distribution of different types of medial plica for each grade of severity of the medial plica was summarized in Table 3. The correlation of mean age with each type of medial plica was statistically significant (P.05) by comparisons for each pair using the Student t test: type A, mean age of 57 years; type B, 52; and type C, 41. Positive correlation was also found between patient age and the severity of the gross appearance of the medial plica by the same test (P.05): grade I, mean age of 30 years; grade II, 43; grade III, 51; grade IV, 58; and grade V, 63. The distribution of each grade of severity in different types of medial plica represented by percentage of knees is shown in Fig 5. For type A medial plicae, there were more grade IV (26.2%) and V (42.2%) lesions than type B (18.7% and 7.8%, respectively) and type C (17% and 2.1%, respectively). For type B medial plicae, there were more grade III lesions (55.7%) than type A (17.5%) and type C (40.4%). For type C medial plicae, there were more grade II lesions (40.4%) than type A (11.2%) and type B (14.2%). There were also more grade III lesions (40.4%) than type A (17.5%) plicae. Two distinct foci of cartilaginous lesion were found on the edge and anterior part of the medial femoral condyle (Foci A and B shown in Fig 4); 97% of knees had lesions over focus A and 94% over focus B. All type C plicae had chondral lesions in both areas. The location and area of these cartilaginous lesions could represent the footprint of the facing medial plica during knee motion. Positive correlation was found between patient age and the severity of the cartilaginous lesion on focus A by comparisons for each pair using Student t test (P.05): normal, mean age of 23 years; stage I, 39; stage II, 50; stage III, 58; stage IV, 62; and stage V, 69 (Table 4). Positive correlation was also found between patient age and the severity of the cartilaginous lesion on focus B by the same test (P.05): normal, mean age of 30 years; stage I, 36; stage II, 49; stage III, 56; stage IV, 59; and stage V, 65 (Table 5). The total degeneration score of the index foci A and B of the medial femoral condyle in different genders for each grade of severity of the medial plica is summarized in Table 6. In each gender, this score was positively correlated with the severity of the plical lesion. The distribution of each stage of severity of the cartilaginous lesion on focus A in different types of medial plica represented by percentage of knee is shown in Fig 6. For type A medial plicae, there were more stage I lesions (20.9%) than type B (13.2%) plicae. For type B medial plicae, there were more stage IV lesions (35.6%) than type A (29.1%) and type C (25.5%) plicae. For type C medial plicae, there were more stage I lesions (29.8%) than type A (20.9%) and type B (13.2%) plicae. The distribution of each stage of severity of the cartilaginous lesion on focus B in different types of medial plicae represented by per-

6 22 S-R. LYU AND C-C. HSU FIGURE 4. Staging of the severity of the cartilaginous lesion on foci A and B. (A) Stage I, neovascularization, pannus formation, softening, no gross indentation. (B) Stage II, neovascularization, pannus formation, softening, indentation. (C) Stage III, indentation with fibrillation. (D) Stage IV, partial-thickness cartilage erosion, broad-based gutter formation. (E) Stage V, full-thickness cartilage erosion and deep gutter formation.

7 MEDIAL PLICAE AND CHONDRAL LESIONS 23 Total Degenerative Score of the Medial Femoral Condyle Facing the Medial Plica TABLE 2. Chondral Lesion (Focus A, B) Score Normal 0 Stage I 2 Stage II 4 Stage III 6 Stage IV 8 Stage V 10 Total Score Score (A B) 0 20 centage of knees is shown in Fig 7. For type A medial plicae, there were more stage IV lesions (41.3%) than type C (29.8%) plicae. For type B medial plicae, there were fewer stage III lesions (21.0%) than type A (32.0%) and type C (31.9%) plicae; however, there were more stage IV lesions (53.4%) than type A (41.3%) and type C (29.8%) plicae. For type C medial plicae, there were more stage I lesions (27.7%) than type A (12.1%) and type B (7.3%) plicae. DISCUSSION The incidence rate reported in the literature of the medial plica varies from 19% to 70%. 1 In our series, the incidence rate was 29.7%. It was higher in female (36.1%) than in male patients (20.8%), and in patients with the diagnosis of osteoarthritis, the incidence was significantly higher (66.9%). The high incidence of medial plica in patients with osteoarthritis has not been reported in the literature before. One of the reasons may be that most studies were dealing with a younger population, with a mean age of less than 30 years, but the mean age of our patients was 48 years. Moreover, we found that the medial plica is always difficult to visualize during arthroscopic examination in the osteoarthritic knee, which may cause its being ignored in elderly patients. In 1939, Iino 5 first described the 4 types of medial FIGURE 5. The distribution of the severity of the pathologic change in different types of medial plica. Note that the pathologic change was more severe in plica with smaller size (type A) and it was less severe in plica with larger size (type C). Statistically significant (P.05, Student t test). shelf based on anatomic dissections of cadaveric knees and this has been followed in most of the literature. Although it is simple, it can only give us the impression of the size of the medial plica. In this study, we classified the medial plica into 3 types by its size according to its relationship with the facing medial femoral condyle when the knee joint is distended by fluid during arthroscopic examination. We further classified them into 5 grades according to their gross appearance. This represents the severity of their pathologic changes. We found that even in the same type of medial plica, there were different degrees of severity of pathologic changes. According to our observation, the medial plica will decrease in size as age increases. This may be attributable to the natural wearing phenomenon in the normal process of aging. It was also noticed that for medial plica with smaller size (type A plica shown in Fig 5), the pathologic change was more severe. Moreover, the degree of severity of the medial plica is positively correlated with patient age. These findings give us some insight into the chronological evolution of the medial plica. TABLE 3. Mean SD (n) of Age by Different Type of Medial Plica for Each Grade of Severity Type Grade I II III IV V Total A (6) (23) (36) (54) 62 9 (87) 57* 13 (206) B (8) (31) 53 9 (122) 57 9 (41) 67 9 (17) 52* 15 (219) C (19) (19) 62 9 (8) 63 (1) 41* 19 (47) Total 30* 11 (14) 43* 17 (73) 51* 15 (177) 58* 10 (103) 63* 9 (105) (472) *Statistically significant by comparisons for each pair using Student t test (P.05).

8 24 S-R. LYU AND C-C. HSU TABLE 4. Mean SD (n) of Age by Different Type of Plica for Each Stage of Severity of Chondral Lesion on Focus A Stage Type n I II III IV V Total A (5) (43) (52) (43) 65 9 (60) 68 5 (3) 57* 13 (206) B 16 4 (9) (29) (43) (57) 61 9 (78) 71 5 (3) 52* 15 (219) C (14) 45 7 (10) (11) 54 8 (12) 0 41* 19 (47) Total 23* 9 (14) 39* 16 (86) 50* 10 (105) 58* 10 (111) 62* 9 (150) 69* 7 (6) (472) *Statistically significant by comparisons for each pair using Student t test (P.05). We postulate that the repeated abrasion between medial plica and the facing medial femoral condyle during daily activities will increase the severity of the pathologic change of the medial plica and also will simultaneously decrease its size due to wear. Degenerative change of the cartilage on the medial femoral condyle adjacent to the pathologic medial plica has been observed and described in many articles. 1,2,7,8,11,12 Most authors state that the pathologic mediopatellar plica snaps or impinges against the underlying femoral condyle during knee motion and leads to erosive changes of the articular cartilage 1,2,7,17 It has been generally accepted that the size of the medial plica was a main determinant of this impingement phenomenon. In a study conducted by Boven et al., 18 the mechanical friction of the medial plica and the condyle could be suspected in 16% of 63 mediopatellar plicae examined by static double-contrast computed tomography scans. The size of the medial plica was thought to be a major factor in causing the impingement. It was also thought that Iino s types A and B are not likely to produce symptoms. Types C and D, because of the width of the plica, are supposed to be the only ones to impinge on the medial condyle. 1 However, in our study, we found that various severities of cartilaginous lesion on the facing medial femoral condyle were commonly found in all types of medial plicae, regardless of their size. And the incidence of this lesion is high according to our observation (97% over focus A and 94% over focus B). These findings remind us that the real relationship of the medial plica with the medial femoral condyle might not be evident during arthroscopic examinations when the joint is distended by fluid. More physiologic dynamic studies may be needed to clarify this abrasion phenomenon. TABLE 5. Mean SD (n) of Age by Different Type of Plica for Each Stage of Severity of Chondral Lesion on Focus B Stage Type n I II III IV V Total A (15) (25) (12) (66) 62 9 (85) 69 7 (3) 57* 13 (206) B 21 9 (14) (16) (19) (46) 58 9 (117) 64 4 (7) 52* 15 (219) C (13) 42 8 (3) (15) 50 9 (14) 61 3 (2) 41* 19 (47) Total 30* 12 (29) 36* 14 (54) 49* 13 (34) 56* 11 (127) 59* 9 (216) 65* 5 (12) (472) *Statistically significant by comparisons for each pair using Student t test (P.05). TABLE 6. Mean SD (n) of Total Degeneration Score by Different Genders for Each Grade of Severity of the Medial Plica Grade Gender I II III IV V Female 0.17* 0.40 (6) 6.66* 5.16 (64) 11.23* 5.47 (48) 13.31* 4.58 (48) 16.12* 3.99 (196) Male 0.00* 2.15 (5) 3.66* 0.81 (35) 10.14* 1.05 (21) 13.20* 1.24 (15) 16.94* 0.82 (34) Total 0.09* 0.30 (11) 5.60* 4.84 (99) 10.90* 5.94 (69) 13.29* 4.98 (63) 16.24* 3.96 (230) *Statistically significant by comparisons for each pair using Student t test (P.001).

9 MEDIAL PLICAE AND CHONDRAL LESIONS 25 In our study, 2 typical areas of degenerative cartilaginous lesions on the femoral condyle facing the medial plica were noted and considered to have direct relationship to the impingement or abrasion caused by the medial plica during knee motion. The gross appearance of the early stage of these lesions, including neovascularization and pannus formation, is different from typical arthroscopic findings of the cartilaginous lesions in osteoarthritic knees. This may be due to different mechanisms of pathogenesis caused by shearing force generated by the abrasion or impingement of the medial plica on the articular surface. Moreover, we found that the severity of these cartilaginous lesions is positively correlated with patient age and the severity of the plical lesion. It was also noted that the cartilaginous lesion on the medial femoral condyle was less severe in patients who had larger medial plica (type C shown in Figs 6 and 7). These findings augment our previous postulation that the repeated abrasion between medial plica and the opposite medial femoral condyle during daily activities will not only increase the severity of the pathologic change of the medial plica but also decrease its size due to wear. This abrasion phenomenon would increase the severity of the damage to the facing medial femoral condyle as the patient s age increased. CONCLUSIONS The incidence of the medial plica was significantly higher in subjects with osteoarthritis of their knees according to our observation. The repeated abrasion between medial plica and the facing medial femoral condyle in daily activities will increase the severity of the FIGURE 6. The distribution of the severity of cartilaginous lesion on focus A in different types of medial plica. Note that the chondral lesion was less severe in larger medial plica (type C). Statistically significant (P.05, Student t test). FIGURE 7. The distribution of the severity of cartilaginous lesion on focus B in different types of medial plica. Note that the chondral lesion was less severe in larger medial plica (type C). Statistically significant (P.05, Student t test). pathologic change of the medial plica and also will simultaneously decrease its size due to wear. Degenerative cartilaginous lesions on the facing medial femoral condyle were found in almost all of the patients who had the structure of medial plica. These lesions have their typical location and pattern of presentation. The severity of these lesions has obvious correlation with patients age and the severity of their plical lesions. REFERENCES 1. Dupont JY. Synovial plicae of the knee. Controversies and review. Clin Sports Med 1997;16: Tindel NL, Nisonson B. The plica syndrome. Orthop Clin North Am 1992;23: Farkas C, Gaspar L, Jonas Z. The pathological plica in the knee. Acta Chir Hung 1997;36: Dandy DJ. Anatomy of the medial suprapatellar plica and medial synovial shelf. Arthroscopy 1990;6: Iino S. Normal arthroscopic findings of the knee joint in adult cadavers. J Jpn Orthop Assoc 1939;14: Flanagan JP, Trakru S, Meyer M, Mullaji AB, Krappel F. Arthroscopic excision of symptomatic medial plica. Acta Orthop Scand 1994;65: Dorchak JD, Barrack RL, Kneisl JS, Alexander AH. Arthroscopic treatment of symptomatic synovial plica of the knee. Long-term follow-up. Am J Sports Med 1991;19: Broom MJ, Fulkerson JP. The plica syndrome: A new perspective. Orthop Clin North Am 1986;17: Andersen E, Poulsen TD. Plica mediopatellaris Arthroscopic resection under local anesthesia. Arch Orthop Trauma Surg 1986;106: Nottage WM, Sprague NF, Auerbach BJ, Shahriaree H. The medial patellar plica syndrome. Am J Sports Med 1983;11: Richmond JC, McGinty JB. Segmental arthroscopic resection of the hypertrophic mediopatellar plica. Clin Orthop 1983;178: Jackson RW, Marshall DJ, Fujisawa Y. The pathologic medical shelf. Orthop Clin North Am 1982;13:

10 26 S-R. LYU AND C-C. HSU 13. Denti M, Monteleone M, Berardi A, Arosio A. Medial patellar synovial plica syndrome: The influence of associated pathology on long-term results. Chir Organi Mov 1994;79: Klein W. The medial shelf of the knee. A follow-up study. Arch Orthop Trauma Surg 1983;102: Schulitz KP, Hille E, Kochs W. The importance of the mediopatellar synovial plica for chondromalacia patellae. Arch Orthop Trauma Surg 1983;102: Tasker T, Waugh W. Articular changes associated with internal derangement of the knee. J Bone Joint Surg Br 1982;64: Strover AE, Rouholamin E, Guirguis N, Behdad H. An arthroscopic technique of demonstrating the pathomechanics of the suprapatellar plica. Arthroscopy 1991;7: Boven F, De Boeck M, Potvliege R. Synovial plicae of the knee on computed tomography. Radiology 1983;147:

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